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Billiman v. Berryhiil

United States District Court, D. New Mexico

March 23, 2017

DANIEL R. BILLIMAN, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          ORDER

          HONORABLE GREGORY J. FOURATT UNITED STATES MAGISTRATE JUDGE

         THIS MATTER is before the Court on Plaintiff's “Motion to Reverse and Remand to Agency for a Rehearing, With Supporting Memorandum” (“Motion”), filed on September 29, 2016. ECF No. 24. The Commissioner responded on December 29, 2016. ECF No. 28. Plaintiff replied on January 12, 2017. ECF No. 29. Having meticulously reviewed the entire record and the parties' pleadings, the Court finds that Plaintiff's Motion is not well taken and that the Administrative Law Judge's (“ALJ's”) ruling should be AFFIRMED. Therefore, and for the further reasons articulated below, the Court will DENY Plaintiff's Motion.

         I. BACKGROUND

         Plaintiff was born on October 19, 1962, in Fort Defiance, Arizona. Administrative R. (“AR”) 311-12. He graduated from Window Rock High School in neighboring Window Rock, Arizona, in 1984. AR 312.[1] From 1993 to 2011, he held semi-continuous employment in general labor and janitorial maintenance positions. AR 22, 209, 234. Plaintiff's last employment as a janitor with Gallup Catholic Schools ended on September 16, 2011, when the contract for the position terminated. AR 22, 312.

         Plaintiff filed an application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) on May 22, 2012. AR 29. Plaintiff claimed disability beginning on September 16, 2011, based on arthritis, a dislocated hip, insomnia, migraines, and acid reflux. AR 244. The Social Security Administration (“SSA”) denied Plaintiff's application initially on October 15, 2012, and upon reconsideration on March 29, 2013. AR 52, 65. At his request, Plaintiff received a de novo hearing before ALJ Ann Farris on April 30, 2014, at which Plaintiff and his attorney appeared.[2] AR 16-28. On August 5, 2014, the ALJ issued her decision, finding that Plaintiff was not disabled within the meaning of the Social Security Act (“the Act”). AR 82-91. Plaintiff appealed to the SSA Appeals Council, but it declined review on December 5, 2015. AR 1-3. As a consequence, the ALJ's decision became the final decision of the Commissioner. 20 C.F.R. § 422.210(a) (2016).

         Plaintiff timely filed his appeal with this Court on February 2, 2016. ECF No. 1.

         II. PLAINTIFF'S CLAIMS

         Plaintiff advances three grounds for relief. First, he argues that the ALJ erred by improperly evaluating the opinion of his treating physician, thereby rendering Plaintiff's residual functional capacity (“RFC”) finding legally infirm. Pl.'s Mot. 5-9, ECF No. 24. Second, he contends the ALJ failed to develop the record regarding his nonexertional limitations and to incorporate these limitations into his RFC, which resulted in a subsequent misapplication of the SSA “grids.” Id. at 10-15. Lastly, he alleges that the SSA Appeals Council incorrectly declined to review relevant evidence. Id. at 15-19.

         III. APPLICABLE LAW

         A. Standard of Review

         When the Appeals Council denies a claimant's request for review, the ALJ's decision becomes the final decision of the agency.[3] The Court's review of that final agency decision is both factual and legal. See Maes v. Astrue, 522 F.3d 1093, 1096 (10th Cir. 2008) (citing Hamilton v. Sec'y of Health & Human Servs., 961 F.2d 1495, 1497-98 (10th Cir. 1992)) (“The standard of review in a social security appeal is whether the correct legal standards were applied and whether the decision is supported by substantial evidence.”).

         The factual findings at the administrative level are conclusive “if supported by substantial evidence.” 42 U.S.C. § 405(g) (2012). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004); Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003). An ALJ's decision “is not based on substantial evidence if it is overwhelmed by other evidence in the record or if there is a mere scintilla of evidence supporting it.” Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214. Substantial evidence does not, however, require a preponderance of the evidence. See Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (citing Zoltanski v. F.A.A., 372 F.3d 1195, 1200 (10th Cir. 2004)). A court should meticulously review the entire record but should neither re-weigh the evidence nor substitute its judgment for that of the Commissioner. Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214.

         As for the review of the ALJ's legal decisions, the Court examines “whether the ALJ followed the specific rules of law that must be followed in weighing particular types of evidence in disability cases.” Lax, 489 F.3d at 1084. The Court may reverse and remand if the ALJ failed “to apply the correct legal standards, or to show . . . that she has done so.” Winfrey v. Chater, 92 F.3d 1017, 1019 (10th Cir. 1996).

         Ultimately, if substantial evidence supports the ALJ's findings and the correct legal standards were applied, the Commissioner's decision stands and the plaintiff is not entitled to relief. Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214, Doyal, 331 F.3d at 760.

         B. Sequential Evaluation Process

         The SSA has devised a five-step sequential evaluation process to determine disability. See Barnhart v. Thomas, 540 U.S. 20, 24 (2003); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4) (2017). At the first three steps, the ALJ considers the claimant's current work activity, the medical severity of the claimant's impairments, and the requirements of the Listing of Impairments. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4), & Pt. 404, Subpt. P, App. 1. If a claimant's impairments are not equal to one of those in the Listing of Impairments, then the ALJ proceeds to the first of three phases of step four and determines the claimant's RFC. See Winfrey, 92 F.3d at 1023; 20 C.F.R. §§ 404.1520(e), 416.920(e). In phase two, the ALJ determines the physical and mental demands of the claimant's past relevant work, and in the third phase, compares the claimant's RFC with the functional requirements of his past relevant work to determine if the claimant is still capable of performing his past work. See Winfrey, 92 F.3d at 1023; 20 C.F.R. §§ 404.1520(f), 416.920(f). If a claimant is not prevented from performing his past work, then he is not disabled. 20 C.F.R. §§ 404.1520(f), 416.920(f). The claimant bears the burden of proof on the question of disability for the first four steps, and then the burden of proof shifts to the Commissioner at step five. See Bowen v. Yuckert, 482 U.S. 137, 146 (1987); Talbot v. Heckler, 814 F.2d 1456, 1460 (10th Cir. 1987).

         If the claimant cannot return to his past work, then the Commissioner bears the burden at the fifth step of showing that the claimant is nonetheless capable of performing other jobs existing in significant numbers in the national economy. See Thomas, 540 U.S. at 24-25; see also Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988) (discussing the five-step sequential evaluation process in detail).

         IV. THE ALJ'S DECISION

         The ALJ issued her decision on August 5, 2014. AR 91. At step one, she found that Plaintiff had not engaged in substantial gainful activity since the alleged disability onset date of September 16, 2011. AR 84. At step two, the ALJ found Plaintiff's bilateral osteoarthritis of the knees and lumbar degenerative disc disease to be severe impairments. AR 84. In contrast, the ALJ found Plaintiff's headaches, right hip pain, acid reflux, left elbow pain, personality disorder (not otherwise specified), and somatoform disorder to be non-severe. AR 85.

         At step three, the ALJ found that none of Plaintiff's impairments, alone or in combination, met or medically equaled the severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1. AR 85-87. The ALJ began with Plaintiff's personality disorder, which she considered under “the four broad functional areas set out in the disability regulations for evaluating mental disorders” and in Listing 12.00(C).[4] In the first functional area, activities of daily living (“ADLs”), the ALJ found Plaintiff had only a mild limitation, as he has “no problem with personal care needs” and performs a wide variety of ADLs. AR 86. In the second area, social functioning, the ALJ found that Plaintiff had “no limitation, ” based on his positive interactions with peers and supervisors and his interview with consultative psychologist Dr. Carl Adams, Ph.D. AR 86. Third, as to Plaintiff's concentration, persistence, and pace, the ALJ found Plaintiff had only a mild limitation. She explained that Plaintiff “does not allege difficulty understanding and following instructions, remembering things, or completing tasks, ” and that when examined by Dr. Adams in October 2012, he was “able to attend and concentrate.” AR 86. Lastly, regarding episodes of decompensation, the ALJ found “little in the record suggesting the claimant has experienced such an episode.” AR 86. Thus, because Plaintiff's “medically determinable impairments cause no more than ‘mild' limitation in any of the first three functional areas and ‘no' episodes of decompensation which have been of extended duration, ” the ALJ found that Plaintiff's mental impairments were both non-severe and insufficient to qualify as presumptively disabling under a relevant Listing. AR 86-87.

         Next, the ALJ considered Plaintiff's physical impairments under relevant Listings. She began with Listing 1.02 for major dysfunction of a joint. To meet that Listing, Plaintiff would have had to establish that his osteoarthritis or hip pain “resulted in an inability to ambulate effectively.” AR 87. At a physical evaluation in May 2014, however, Plaintiff “demonstrated the ability to walk with only a minimally antalgic gait.” AR 87. Accordingly, the ALJ found Plaintiff did not meet or medically equal the requirements of Listing 1.02.

         Additionally, the ALJ considered Plaintiff's lumbar degenerative disc disease under Listing 1.04 for disorders of the spine. The ALJ explained that, to qualify under that Listing, “a claimant must show a disorder of the spine resulting in compromise of a nerve root or spinal cord.” AR 87. Moreover, a qualifying claimant must also demonstrate one of the following: “evidence of nerve root compression, spinal arachnoiditis, or lumbar spinal stenosis resulting in pseudoclaudication, with an inability to ambulate effectively.” AR 87. The ALJ found none of these present in Plaintiff, as a magnetic resonance imaging (“MRI”) scan performed on May 30, 2014, provided “no evidence of stenosis.” AR 87. At his physical evaluation that same month, Plaintiff was also able to ambulate “with only a minimally antalgic gait.” AR 87. Taken in tandem, this evidence led the ALJ to conclude that Plaintiff's impairment “does not meet or medically equal [L]isting 1.04.” AR 87.

         Because none of Plaintiff's impairments satisfied an applicable Listing, the ALJ moved on to step four and assessed Plaintiff's RFC. AR 37-42. “After careful consideration of the entire record, ” the ALJ determined that “[Plaintiff] has the residual functional capacity to perform the full range of light work” as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b). AR 87.

         To develop Plaintiff's RFC, the ALJ relied on two principal grounds. First, the ALJ rendered an adverse credibility finding against Plaintiff, opining that Plaintiff's “allegations regarding the disabling effects of his impairments are not entirely credible.” AR 88. The ALJ discerned multiple “inconsistencies in the record” and summarized them thus:

Despite alleging disabling symptoms, [Plaintiff] has no problem with his personal care needs. He is also able to prepare complete meals, do house work, chop wood, clean his yard, leave the house alone, drive, go shopping, pay bills, count change, handle a savings account, [ ] use a checkbook . . . [and] is able to walk up to a mile before having to stop and rest.

AR 87. Collectively, the ALJ found “[t]hese abilities [to be] inconsistent with allegations of disability.” AR 88. In addition, the ALJ discussed the consultative report prepared by Dr. Adams in October 2012, which documented Plaintiff getting up from a chair without difficulty, carrying a large satchel with ease, and walking down a hall with virtually no pain behavior, but, when placed in an examination room and aware of the examiner's presence, Plaintiff began exhibiting “exaggerated grunts and groans.” AR 88 (quoting AR 311). Plaintiff's conduct led Dr. Adams to conclude that Plaintiff's “verbalized complaints [were] inconsistent with his behavioral presentation.” AR 88 (quoting AR 311). Lastly, the ALJ reflected on Plaintiff's administrative hearing testimony, which included his admission that he quit working not due to a disability, but because “his contract ran out.” AR 88. See AR 22.[5] This, too, “further reduced” Plaintiff's credibility, and “taken together” with other facts in the record, resulted in the ALJ finding that Plaintiff's “allegations regarding the disabling effects of his impairments are not entirely credible.” AR 88.

         Along with Plaintiff's adverse credibility finding, the ALJ also relied on the medical evidence of record to determine Plaintiff's RFC. Following her review, the ALJ opined that “the objective findings in this case fail to provide strong support for [Plaintiff's] allegations of disabling symptoms and limitations resulting from his severe impairments.” AR 88. Specifically, she documented Plaintiff's treatment both for knee and back pain from 2012 through 2014. See AR 88-89. Even in records post-dating his administrative hearing by one month, [6] the ALJ noted that Plaintiff's gait was “minimally antalgic, ” and that he “displayed full range of motion.” AR 89. Moreover, in May 2014, an MRI taken of Plaintiff's lower back showed a[n] ¶ 5-S1 annular tear[7] with multilevel loss of disc height, ” but the ALJ highlighted that “no stenosis was present.”[8] AR 89 (citing AR 399-402).

         The ALJ closed her RFC analysis by discussing the medical opinions in the record. First, she accorded great weight to the opinion of consultative examining psychologist Dr. Carl Adams, who “stated the [Plaintiff] does not have a severe mental impairment.” AR 89. Next, she assigned “some weight” to the opinion of Dr. Sterling Moore, M.D., the non-examining state medical consultant, “who stated [Plaintiff] can perform light work with some postural limitations.” AR 89. Finally, the ALJ discounted the opinion of Plaintiff's treating physician, Dr. Dylan Stentiford, M.D. In a “Physical Capacities Evaluation” completed by Dr. Stentiford on June 7, 2013 [AR 364-365], he concluded that Plaintiff could “sit for no more than 2 hours per day and stand or walk for no more than four hours per day.” AR 90. Moreover, Dr. Stentiford “limited [Plaintiff] to lifting at the sedentary extertional level.” AR 90. Although the ALJ acknowledged that “[a] treating physician's opinion is usually entitled to some weight, ” she found “little to no support in the medical evidence” for Dr. Stentiford's opinion. AR 90. She reasoned that “x-rays of [Plaintiff's] hip showed no abnormalities, ” and “[x]-rays [of Plaintiff's knees] found only early degenerative changes.” AR 90 (citing AR 332, 334-35). Similarly, the ALJ observed that “despite [Plaintiff's] complaints of disabling knee pain, [Plaintiff] exhibited good range of motion in the joint.” AR 90 (citing AR 333). Most importantly, the ALJ found that Dr. Stentiford's “treatment notes do not support the degree of limitation in his medical source statement.” AR 90.

         At step four, the ALJ found that Plaintiff could not perform any past relevant work. AR 90. Accordingly, the ALJ proceeded to step five. Based on Plaintiff's age, education, work experience, and RFC, the ALJ found that Plaintiff could perform other jobs that exist in significant numbers in the national economy. AR 90. No specific job titles or descriptions were given for these jobs, as the ALJ found Plaintiff capable of “the full range of light work.” AR 91. Finally, the ALJ found that Plaintiff had not been under a disability, as defined by the Act, during the relevant time period and denied his claim. AR 91.

         V. ANALYSIS

         As set forth below, Plaintiff has failed to marshal sufficient support from facts or case law to establish that the ALJ applied incorrect legal standards or that her decision is unsupported by substantial evidence. Consequently, his Motion must be denied. The Court's reasoning as to each of Plaintiff's three claims will be discussed seriatim.

         A. The ALJ Properly Evaluated the Opinion of Plaintiff's Treating Physician

         Plaintiff raises two objections to the ALJ's treating physician analysis. First, Plaintiff questions the evidentiary basis for Plaintiff's RFC, arguing that “the ALJ failed to support [Plaintiff's] RFC finding with substantial evidence, and in so doing improperly rejected a treating doctor opinion.” Pl.'s Mot. 5. He notes how “[the ALJ] stated she gave treating Dr. Stentiford's opinion little weight because the opinion finds little to no support in the medical evidence.” Id. at 9. But he takes exception to the ALJ's citation to “one hip x-ray that showed ‘no abnormalities' and one record that [Plaintiff] had good range of motion in his knee joint.” Id. These citations notwithstanding, Plaintiff contends that the ALJ “failed to discuss other evidence, including the MRI [which] showed an annular tear at ¶ 5-S1 with multilevel loss of disc height, as well as severe chondromalacia[9] and degenerative changes in the right knee.” Id. (citing AR 402, 407).

         Additionally, Plaintiff argues that the ALJ's treating physician analysis is legally deficient. He reasons that “Social Security regulations require the ALJ to give the opinion of treating physicians controlling weight when the opinion is well-supported by the medical evidence and consistent with the record.” Id. at 8. He also describes that “[i]n assessing Dr. Stentiford's opinion, [the ALJ] was required to follow two distinct steps, ” but by Plaintiff's estimation, the ALJ erred at both. Id. at 8-9.

         The Commissioner responds that the ALJ “gave good reasons for discounting” Dr. Stentiford's opinion, “noting that it was inconsistent with objective medical evidence in the record and inconsistent with his own treatment notes.” Def.'s Resp. 8, ECF No. 28. She also characterizes Dr. Stentiford's recommendations as “work-preclusive, outlier limitations, ” id., and contrasts them with the same portions of the record highlighted by the ALJ. See Id. at 8-9. The Commissioner emphasizes that the ALJ properly performed the two steps of the treating physician analysis, even though the ALJ did not expressly cite all of the regulatory factors. In defending the ALJ, the Commissioner also cites authority ...


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