Opinion
Civil Action No. 10-12221-DJC
12-22-2011
MICHELLE CIOPPA, Plaintiff, v. MICHAEL J. ASTRUE, COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
MEMORANDUM AND ORDER
CASPER, J.
I. Introduction
Plaintiff Michelle Cioppa ("Cioppa") filed claims for disability insurance benefits ("SSDI") and supplemental security income ("SSI") with the Social Security Administration ("SSA"). Pursuant to the procedures set forth in the Social Security Act, 42 U.S.C. §§ 405(g), 1383(c)(3), Cioppa brought this action for judicial review of the final decision of the Defendant Michael J. Astrue, Commissioner of the SSA ("the Commissioner"), issued by an Administrative Law Judge ("ALJ") on June 25, 2010, denying her claim. Before the Court are Cioppa's Motion to Reverse or Remand the ALJ's decision and the Commissioner's Motion to Affirm that decision. In her motion, Cioppa claims that the ALJ erred in denying her claim because: i) the ALJ ignored Cioppa's migraine headaches; and ii) the ALJ failed to contact two treating physicians to clarify the basis of their opinions before disregarding them as ambiguous or unsupported. Because the ALJ adequately considered Cioppa's migraine headaches and the opinions of the two treating physicians were not supported by medical evidence and were inconsistent with the record as a whole, the Commissioner's final decision is AFFIRMED.
II. Factual Background
Cioppa was 28 years old when she ceased working on March 15, 2002. R.184, 188. She had previously worked as a general office clerk, nurse's aide, residential counselor and legal claims clerk. R. 96-97, 211. Cioppa filed her application for SSDI on October 17, 2008 and filed her application for SSI on November 6, 2008. R. 184, 188. She alleged disability due to bipolar disorder, a rotator cuff injury, neck pain, fibromyalgia and vertigo. R. 204.
On Cioppa's SSI application summary, the SSA stated that Cioppa claimed a disability onset date of January 1, 2002. However, March 15, 2002 is the onset date Cioppa used on her application and the date used by the ALJ. R. 9, 204. On Cioppa's SSDI application, the SSA stated that Cioppa claimed a disability onset date of December 30, 2005 so as to comply with SSA requirements that a claimant be insured for disability at the time she became disabled. R. 184. The ALJ stated that "claimant's earnings record shows that the claimant has acquired sufficient quarters of coverage to remain insured through December 31, 2005," thereby satisfying SSA requirements. R. 7; 42 U.S.C. §§ 216(i), 223(E).
Citations to the administrative record in this case, Docket No. 8, shall be to "R. ___."
III. Procedural History
After the SSA's initial review of Cioppa's claims, her claims were denied on February 13, 2009. R. 117. Her claims were reviewed by a Federal Reviewing Official and again denied on June 4, 2009. R. 127. On June 10, 2009, Cioppa filed a timely request for a hearing before an ALJ pursuant to SSA regulations. A hearing was held before an ALJ on May 4, 2010. R. 26. In a written decision dated June 25, 2010, the ALJ determined that Cioppa did not have a disability within the definition of the Social Security Act and denied Cioppa's claims. R. 8.
IV. Discussion
A. Legal Standards
1. Entitlement to Disability Benefits and Supplemental Security Income
A claimant's entitlement to SSDI and SSI turns in part on whether she has a "disability," defined in the Social Security context as an "inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than twelve months." 42 U.S.C. §§ 416(i), 423(d)(1)(a); 20 C.F.R. § 404.1505. The inability must be severe, rendering the claimant unable to do his or her previous work or any other substantial gainful activity which exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511.
The Commissioner must follow a five-step process when he determines whether an individual has a disability for Social Security purposes and, thus, whether that individual's application for benefits will be granted. 20 C.F.R. § 416.920. All five steps are not applied to every applicant; the determination may be concluded at any step along the process. Id. First, if the applicant is engaged in substantial gainful work activity, then the application is denied. Id. Second, if the applicant does not have, or has not had within the relevant time period, a severe impairment or combination of impairments, then the application is denied. Id. Third, if the impairment meets the conditions for one of the "listed" impairments in the Social Security regulations, then the application is granted. Id. Fourth, if the applicant's "residual functional capacity" ("RFC") is such that he or she can still perform past relevant work, then the application is denied. Id. Fifth and finally, if the applicant, given his or her RFC, education, work experience, and age, is unable to do any other work, the application is granted. Id.
2. Standard of Review
This Court has the power to affirm, modify, or reverse a decision of the Commissioner upon review of the pleadings and record. 42 U.S.C. § 405(g). Such review, however, is "limited to determining whether the ALJ deployed the proper legal standards and found facts upon the proper quantum of evidence." Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999) (citing Manso-Pizarro v. Sec'y of Health and Human Servs., 76 F.3d 15, 16 (1st Cir. 1996)). The ALJ's findings of fact are conclusive when supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence exists "if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [the Commissioner's] conclusion." Rodriguez v. Sec'y of Health and Human Servs., 647 F.2d 218, 222 (1st Cir. 1981).
B. Evidence before the ALJ
1. Medical History
The evidence before the ALJ included Cioppa's medical history, including diagnoses and treatment, particularly in regard to the conditions upon which Cioppa relied in claiming a disability in her application for benefits. Cioppa claimed "[b]ipolar disorder, rotator cuff, neck pain, [f]ibromyalgia, [and] [v]ertigo." R. 204. The ALJ defined Cioppa's medical impairments as "bipolar disorder, substance abuse, fibromyalgia, left wrist pain possibly associated with carpel tunnel syndrome, chronic endometriosis, and a rotator cuff injury post-arthroscopy." R. 9.
a. Bipolar Disorder
On April 1, 2009, Cioppa's primary care physician, Dr. Calvin Lee, stated that Cioppa had bipolar disorder and suffered from anxiety and headaches. R. 383. Dr. Lee assessed her mood to be at times depressive and manic. Id. Still, Dr. Lee stated that Cioppa was "capable and desiring to work." R. 384. He further assessed that Cioppa had "great potential to contribute to society, and that working would provide [her] a sense of purpose." Id. Dr. Lee also mentioned that Cioppa's psychiatrist, Dr. J. Philip Reimherr, prescribed her with Klonopin and Clondine to help ease her psychiatric issues. R. 384, 620.
On February 17, 2010, Dr. Reimherr met with Cioppa to evaluate her for state benefits through the Emergency Aid to Elders, Disabled and Children ("EADC") program. R. 619. Cioppa told Dr. Reimherr, that she "has paranoid thoughts quite frequently." Id. Still, Dr. Reimherr gave Cioppa a Global Assessment of Functioning Score of 55. R. 619. On April 4, 2010, Dr. Reimherr stated in his mental RFC assessment that Cioppa had marked limitations in her ability to understand, remember and carry out detailed instructions and in her ability to maintain attention and concentration for extended periods of time. R. 633. However, Dr. Reimherr also noted that Cioppa had good social skills, could respond appropriately to changes in work setting, and had no significant limitations in her ability to understand and carry out very short and simple instructions. R. 633-35. Dr. Reimherr diagnosed Cioppa with bipolar II disorder, post-traumatic stress disorder, and cannabis dependence. R. 637. He also stated that Cioppa experienced "daily headaches" of "decreasing intensity" as a side effect of her medication. Id. Dr. Reimherr believed that Cioppa was disabled from "competitive substantial gainful employment." Id. On April 14, 2010, Cioppa informed Dr. Reimherr that "she has been using marijuana in large amounts on a daily basis which caused her some . . . difficulty functioning . . . she knows that this has been some of her problem but not all." R. 741.
"The GAF scale is used to report a clinician's judgment of an individual's overall level of psychological, social and occupational functioning and refers to the level of functioning at the time of evaluation." Vazquez v. Astrue, 2011 WL 1564337, at *1 n.1 (D. Mass. Apr. 25, 2011) (citing American Psychiatric Ass'n, Diagnostic and Statistical Manual of Mental Disorders 32-33 (4th ed., text rev. 2000) (hereinafter "DSM-IV")). A GAF of 51-60 indicates "moderate symptoms or moderate difficulty in social or occupational functioning." Pina v. Astrue, 2007 WL 2071791, at *1 n.3 (D. Mass. July 18, 2007) (citing DSM-IV 34).
On a more frequent and consistent basis Cioppa met with Sheryl Rosen, Registered Nurse and Clinical Specialist, who practices in the same psychiatric office as Dr. Reimherr. R. 617-19, 280-348. On October 14, 2005, Ms. Rosen diagnosed Cioppa with bipolar II disorder and cannabis dependence. R. 348. Between 2005 and 2009 Ms. Rosen had attempted to find a medication regimen to help Cioppa with mood stabilization, alleviate her sleep difficulties and soothe headaches, which proved difficult because of Cioppa's allergies to many of the drugs and ensuing side effects. R. 280, 294, 337, 348, 441, 444-45, 625. Cioppa would experience mood swings; for example, on March 6, 2006 Cioppa "report[ed] that her mood presently is up," even though she had to discontinue using Zonegran as a mood stabilizer because it caused yeast infections as a side effect. R. 464. On June 21, 2006, Ms. Rosen gave Cioppa a GAF score of 48, R. 455, but on January 23, 2008, Ms. Rosen gave her a GAF score of 55, noting that Cioppa's "mood has presently cycled into a stable place." R. 444. On January 12, 2010, Cioppa reported that she had "begun to exercise again and is feeling alive again." R. 622. However on April 7, 2010, Cioppa reported to Ms. Rosen that her troubles with sleep and continued anxiety had returned. R. 617. Still, Ms. Rosen gave her a GAF score of 55 and recommended new medication for her, along with an appointment with a neuropshychologist for testing. Id. In 2009, Cioppa began seeing a psychotherapist, Laura O'Meara, and reported that she was benefitting from treatment. R. 626.
A GAF of 41 to 50 reflects "serious symptoms or any serious impairment in social, occupational, or school functioning." Kiklis v. Astrue, 2011 WL 4768491, at *4 n.2 (D. Mass. Sept. 28, 2011) (citing DSM-IV 34).
On January 8, 2009, Dr. Jane Metcalf completed a mental RFC assessment of Cioppa on behalf of the SSA. R. 366. She determined that Cioppa could sustain focus and pace on simple tasks, understand instructions, work well with others, and adapt well to a structured occupational setting. R. 366. She also stated that Cioppa was not significantly limited in her social interaction and had only mild restrictions on activities of daily living. R. 360, 364.
b. Substance Abuse
Cioppa has a long history of substance abuse since the age of 12, with bouts of sobriety and relapse. R. 347. On September 12, 2006, Cioppa reported to Ms. Rosen that "she did relapse again on marijuana and cocaine. She will be 30 days free of this on Wednesday. Since she has stopped using cocaine and marijuana she finds that her migraines have gone away. She has been 3 weeks now without migraines." R. 320.
On February 9, 2007, Cioppa told Ms. Rosen that she moved to an apartment that is closer to "an AA meeting which she likes and will plan to attend." R. 306. On July 18, 2008, Ms. Rosen encouraged Cioppa to stay away from marijuana because of the negative impact it had on her mood and emotions. R. 348. While Dr. Reimherr diagnosed Cioppa with cannabis dependence in his mental RFC assessment, he noted that her substance abuse could not be deemed self-medication. R.637. On April 30, 2010, Cioppa reported sobriety from marijuana usage and stated that she has been attending drug addiction meetings. R. 735. As of the date of the hearing before the ALJ on May 4, 2010, Cioppa testified that she was 30 days free of marijuana use and was attending meetings everyday. R. 62.
c. Fibromyalgia
Dr. Lee diagnosed Cioppa with fibromyalgia, noting that she often felt recurring pain. R. 383. On her SSDI application, Cioppa wrote that she is "unable to do anything physical because of pain." R. 204. Cioppa noted frustration because medication was not working for her, but Dr. Lee expressed his concern with Cioppa's increased dependency on narcotic pain medications such as Percocet, prescribed by other doctors. R. 383-84. On January 24, 2008, Cioppa met with rheumatologist Dr. Dwight Robinson, who noted that Cioppa had "symptoms and findings consistent with . . . fibromyalgia" and recommended Cioppa try a new medication, Neurontin. R. 69, 388. However, Cioppa also admitted to having good days and bad days regarding the pain. R. 552. Dr. Lee discussed with Cioppa the benefit of aerobic conditioning to alleviate some of the pain, in lieu of the dangerous cycle of addiction that prescription narcotics could have. R. 412.
d. Left Wrist Pain/Carpel Tunnel Syndrome
On her SSDI application, Cioppa noted that she has to use a wrist brace when "moving around." R. 230. On April 14, 2005, orthopedic surgeon Dr. Brian J. Awbrey examined Cioppa and determined that Cioppa had slight abnormality in the usage of her thumb and that she has mild carpal tunnel. R. 558. On May 2, 2007, additional tests showed that Cioppa's hand and finger swelling could be associated with inflammatory arthritis, but this examination was not conclusive. R. 560. A physical examination by Dr. Robinson revealed "no objective evidence for joint disease of the small joints of the hand, wrists, feet, and ankles." R. 388.
e. Chronic Endometriosis
Cioppa has also suffered from endometriosis for a considerable amount of time. R. 478. She experiences abnormal uterine bleeding, for which a hysteroscopy was attempted but not completed because Cioppa experienced extreme discomfort in the process. R. 486, 491. The origin of her endometriosis is unclear. R. 563. In 2009, examinations of her pelvic and vaginal area were unremarkable, although Cioppa was experiencing pelvic pain. R. 577, 579. Doctors attributed some of Cioppa's pain to a possible urinary tract infection. R. 569. However, two fibroids were found on her endometrium. R. 593. Cioppa had surgery for minimal endometriosis on November 9, 2009 but her symptoms did not seem to improve. Id., R. 584.
f. Rotator Cuff Injury Post-Arthroscopy
On April 11, 2003, Dr. Awbrey performed rotator cuff arthroscopy (surgery) because of a partial rotator cuff tear and attempted to relieve Cioppa of pain in her shoulder and neck. R. 669-70. Post-surgery, Cioppa continued to experience pain. R. 529. In his treatment notes, Dr. Awbrey often stated that Cioppa was "totally disabled." R. 532-34, 538-39, 542. However Cioppa reported to Dr. Awbrey that she had her "good and bad days." R. 552. MRIs between 2005 to 2009 revealed unchanged, minor abnormality and strains in her cervical spine, left thumb and left wrist. R. 554-60. On February 3, 2009, Dr. R. Roger Komer conducted a consultive examination of Cioppa. R. 369-72. While he did note slight tenderness in Cioppa's cervical spine and right and left shoulders, along with lower back pain, he did not find it limiting, stating Cioppa "has slightly decreased range of motion of the right shoulder, and the left shoulder also had a limitation of movement but it appeared normal." R. 370-72. He noted that Cioppa had a normal gait and her physical examination was mostly normal. R. 371.
On February 9, 2009, Dr. Theresa Kriston completed a physical RFC assessment of Cioppa on behalf of the SSA. R. 373-80. Although she acknowledged the tenderness in Cioppa's shoulder and neck that resulted in pain, Dr. Kriston determined that Cioppa could lift and/or carry up to 20 pounds occasionally and up to 10 pounds frequently; that she could sit, stand and/or walk for about 6 hours each in an 8-hour work day; that she could occasionally reach overhead, but that she had no other manipulative limitations; and that she could occasionally climb, balance, stoop, kneel. R. 374-76.
On April 20, 2009 Dr. Richard Goulding completed a physical RFC assessment of Cioppa on behalf of the SSA. R. 496-503. He also acknowledged tenderness and pain in Cioppa's shoulders, back and spine and Cioppa's complaint of headaches, but after reviewing her record, he determined that Cioppa could lift twenty pounds occasionally with some upper extremity limitations. R. 497. He determined that Cioppa could also lift and/or carry ten pounds frequently and sit, walk and/or stand for about 6 hours each in an 8-hour workday. Id.
2. ALJ Hearing
At the May 4, 2010 administrative hearing, the ALJ heard testimony from Cioppa and vocational expert ("VE") Dr. Amy E. Vercillo. R. 26.
a. Cioppa's Testimony
Cioppa testified that prior to her medical impairments, she worked as a legal claims clerk, as a desk clerk, as a nurse's aide and as a residential counselor at a facility for psychiatric patients. R. 43-48. Cioppa testified that she had difficulty sustaining employment because of her pain, which would force her to stay at home many days. R. 38-39. When asked why she left the position of legal claims clerk, Cioppa stated "[p]hysical, the same reason why I've lost every other job I've had, physical problems. I couldn't even use the mouse for the computer anymore . . . just anything physical it was like wrists, hands, arms, shoulders." R. 38-39. Prior to the onset of her pain, Cioppa also testified that she received a license to practice as an aesthetician. R. 39-40. Cioppa could not recall if there was anything significant about the particular onset date she wrote on her SSI and SSDI applications. R. 40.
Cioppa testified that both her physical and mental impairments were preventing her from working. R. 84. When asked exactly what she is unable to do, Cioppa responded "[j]ust about anything now." R. 55. Cioppa also testified that attending physical therapy makes her fibromyalgia worse. R. 56. She gave the ALJ a recitation of the medications that she uses for her symptoms, including what has and has not worked. R. 69-74. Cioppa stated that the endometriosis caused her "pain on a daily basis" and stated that she felt the pain as she was testifying. R. 75-76. As to the pain in her hand, Cioppa testified that swelling occurs "pretty much . . . in both hands . . . just today it's this hand, some days it's both hands." R. 78. Because of this pain, Cioppa testified that she is unable to do chores around the house. R. 78-79. Claiming that she is unable to lift a gallon of milk, Cioppa stated that her condition has deteriorated to its current state over the past two or three years. R. 80. Although Cioppa stated earlier that she felt swelling in one of her hands and felt pain from the endometriosis, when the ALJ asked her if "[t]here are some days when you might say you feel okay?", Cioppa responded "I'm all right today, yeah." R. 80.
When Cioppa experienced anxiety, stress, nervousness or any "kind of trauma physically or mentally," she testified that her fibromyalgia worsened. R. 82. She testified that she was involved in a motor vehicle accident that aggravated her physical and mental impairments. Id. Cioppa further testified that she has good social skills and has never had a problem respecting authority or a supervisor at work. R. 85. Cioppa's attorney asked her about the migraine headaches she sometimes experiences. R. 88. When asked how often they occur, Cioppa testified "I go through spurts where I could get them and they last for weeks on end, over two to three weeks, even more sometimes day and night from the minute I wake up until I go to bed at night." Id. Cioppa also testified about her psychiatric issues, her inability to sleep on many nights, and her use of cannabis as a coping mechanism that soon became "addictive." R. 88-94. Cioppa also noted the impact her past unstable relationships and marriage has had on her mental health. R. 91.
b. Dr. Vercillo's Testimony
The VE, Amy Vercillo, testified that she was present during Cioppa's testimony and had an opportunity to review the documents included as exhibits. R. 96. She mentioned Cioppa's past work as a legal claims clerk, a home health aide, a nurse's aide, a resident counselor, and a general office clerk. R. 96-97. Dr. Vercillo testified that Cioppa's work as a home health aide, nurse's aide and resident counselor all qualified as medium, semi-skilled occupations. Dr. Vercillo classified Cioppa's work as a general office clerk as a light, semi-skilled occupation. R. 96. Finally, her work as a legal claims clerk was classified as a sedentary, semi-skilled position. R. 96-97. The ALJ asked Dr. Vercillo to consider the following hypothetical for Cioppa:
The following residual functional capacity that out of an eight-hour day she can sit, stand, or walk in combination six hours each; that she could occasionally lift 20 pounds; 10 pounds more frequently; that she is limited to only occasional pushing and pulling with her upper extremities . . . can understand instructions . . . able to sustain her focus and pace on simple tasks . . . in light of the impact of her stress that she needs to have only occasional changes in her work setting; that she has no deficit in social functioning except that her interactions with co-workers need to be work-related . . . simply because of the distractability that she's working with others. Given that residual functional capacity would she be able to perform any of her past work? R. 97-8.Dr. Vercillo responded that these limitations would prevent Cioppa from performing her prior work as a nurse's aide, health home aide and residential counselor, but she would be able to work in some positions as a general office clerk or front desk clerk. R. 99. Altering the question slightly for Cioppa's mental issues and possible problems focusing, the ALJ asked Dr. Vercillo if any jobs existed for Cioppa in the national economy if she had to refocus after two hours of work, even without any problems with social functioning. R. 99-100. Dr. Vercillo responded that this hypothetical would "allow for sedentary, unskilled, and in particular based [on] these hypotheticals, sedentary, unskilled clerical support kinds of occupations [like] an individual who is doing order checking, checking for accuracy . . . bill sorter . . . collator and mailer." R. 103. The VE further testified that if the same hypothetical claimant could not sustain focus more than 20 percent of the time out of a typical workday, or if the claimant had marked limitations from psychologically-based symptoms that consistently interrupted the flow of her workday, then that person would be precluded form employment even in the unskilled labor market. R. 104, 106.
3. Findings of the ALJ
Following the five-step process, 20 C.F.R. § 416.920, at step one, the ALJ found that Cioppa has not engaged in substantial gainful activity since March 15, 2002, the alleged disability onset date. R. 9. Cioppa does not dispute the ALJ's findings at step one.
At step two, the ALJ found that Cioppa had the following severe impairments: bipolar disorder, substance abuse, fibromyalgia, left wrist pain possibly associated with carpal tunnel syndrome, chronic endometriosis and a rotator cuff injury post-arthroscopy. Id. Cioppa does dispute the Commissioner's determination regarding her severe impairments. Pl. Br. 11.
At step three, the ALJ found that Cioppa did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. R. 10. Cioppa does not dispute the ALJ's findings at step three.
Before reaching her step four finding, the ALJ determined Cioppa's residual functional
capacity, finding that Cioppa:
has the [RFC] to perform less than the full range of sedentary work as defined in 20 C.F.R. 404.1567(a) and in 20 C.F.R. 416.967(a). The claimant can stand for two hours and sit for six. She can lift/carry 10 pounds occasionally and less than 10 poundsConsequently, at step four, the ALJ determined that Cioppa cannot perform any of her past relevant work as a legal claims clerk, a residential counselor, a home health aide, or a general office clerk because she retains the ability to perform sedentary and unskilled work, with a need to refocus every four hours. R. 17. Cioppa disputes the ALJ's RFC assessment, Pl. Br. 11, but does not dispute the ALJ's findings at step four, namely, that Cioppa is precluded from performing her past relevant work.
frequently. She cannot climb ropes, ladders, or scaffolds, and cannot bend to pick up objects from the floor or crawl. She can occasionally climb stairs and ramps, stoop, balance, kneel, and crouch. . . . [s]he can frequently handle, finger and feel. She needs to avoid concentrated exposure to extreme cold, fumes, odors, and gases, and to avoid more than moderate exposure to hazards. She is able to do unskilled work requiring a commonsense understanding to carry out detailed but uninvolved written or oral instructions. R. 11.
At step five, the ALJ found that despite Cioppa's limited physical and mental impairments, Cioppa is able to perform other work that exists in significant numbers in the national economy. R. 17. As a result, the ALJ found that Cioppa was not disabled since March 15, 2002, her alleged disability onset date. R. 8. Cioppa disputes this finding. Pl. Br. 11-16.
C. Cioppa's Challenges to the ALJ's Findings
Cioppa contends that the ALJ erred by (1) failing to consider Cioppa's migraine headaches; and (2) failing to contact Dr. Reimherr and Dr. Awbrey, two of her treating physicians, for clarification about the basis of their opinions, which respectively stated that Cioppa is disabled and that her impairments precluded her from competitive substantial gainful employment. R. 532, 637. Cioppa's first challenge relates to the ALJ's determination at step two and analysis at step four. The second challenge relates to the ALJ's RFC determination and findings at step five. For the reasons discussed below, Cioppa's arguments fail.
1. Cioppa's Migraine Headaches
Cioppa argues that the ALJ misapplied 20 C.F.R. §404.1529 by ignoring her complaint of migraine headaches and the impact they have on her ability to work. Pl. Br. 11-12.
At step two, the ALJ must determine whether a claimant suffers from a "severe impairment that significantly limits the claimant's physical or mental ability to do basic work activities." White v. Astrue, 2011 WL 736805, at *6 (D. Mass. Feb. 23, 2011) (quoting Bowen v. Yuckert, 482 U.S. 137, 141-42 (1987)). The plaintiff carries the burden at step two to prove that she suffers from a "severe impairment" that "significantly limits" her ability to perform basic work activities. Bowen, 482 U.S. at 141-42. To meet this burden, a claimant must use "objective medical evidence" to demonstrate that his or her condition meets the above standard of severity. White, 2011 WL 736805, at *6 (internal quotations omitted). Here, Cioppa has not met this burden.
The record lacks any objective medical evidence regarding the severity of Cioppa's migraine headaches. The record before the ALJ revealed that on October 24, 2005, Cioppa went to the emergency room and complained of, among other things, a severe migraine headache. R. 691. Her discharge report stated that Cioppa's headache "was evaluated by a physical exam, labs, and a head CT, all of which were normal." Id. Cioppa was "given IV fluids and medicines for [her] headache which seem to have worked to some degree" and was discharged that same day. Id. On May 2, 2006, Cioppa returned to the emergency room, complaining again of migraine headaches. R. 690. She was discharged in stable condition that same day and "given printed instructions for [her] headache." Id. Cioppa argues that she was diagnosed with a severe headache during her emergency room visits, but "a mere diagnosis of a condition says nothing about the severity of the condition." Id. That Cioppa was released from the emergency room on the same day of her visits, showed improvement with the use of medication, and had normal test results all undermine her claim. Without any objective evidence to the contrary, Cioppa's subjective complaints of headaches will not establish disability. See 20 C.F.R. §404.1529(a) (stating that "statements about . . . pain or other symptoms will not alone establish that you are disabled; there must be medical signs and laboratory findings which show that you have a medical impairment").
In fact, Cioppa herself failed to list headaches as one of her impairments on her SSA application. R. 204. Such failure undermines Cioppa's own allegations regarding the severity of the headaches and the impact they have on her ability to work. See Gray v. Heckler, 760 F.2d 369, 374 (1st Cir. 1985) (noting that plaintiff's failure to allege an impairment on an SSA application is a relevant consideration in the determination of disability benefits). Therefore, Cioppa cannot now allege that the headaches are a severe impairment ignored by the ALJ.
Moreover, despite the lack of objective medical evidence, the record shows that the ALJ did not ignore Cioppa's complaints concerning her migraines. The ALJ is required to consider all of a claimant's "statements about . . . symptoms, such as pain, and any description [claimant or claimant's] treating source or nontreating source . . . may provide about how the symptoms affect [claimant's] activities of daily living and . . . ability to work." 20 C.F.R. §404.1529(a). The ALJ was aware of Cioppa's complaint of headaches, as Cioppa was questioned about it during the hearing before the ALJ. R. 88. Additionally, the ALJ made note of Dr. Reimherr's mental RFC assessment regarding headaches as a side effect of Cioppa's medication. R. 13. In making her decision, the ALJ also relied on the treatment reports of Dr. Lee and Dr. Goulding, who both concluded that Cioppa was not disabled from employment, despite headaches and other limitations. R. 12, 16, 384, 496-503. Therefore, the record shows that the ALJ did consider Cioppa's complaints of headaches in making her finding.
It is unclear whether the headaches are a result of side effects from medication for Cioppa's pain or a side effect of her substance abuse. Inasmuch as they are a result of her cannabis dependence and cocaine use, the ALJ has to determine whether a "drug addiction . . . is a contributing factor material to the determination of disability. . . . "[i]n making this determination, [the ALJ] will evaluate which of [claimant's] physical and mental limitations . . . would remain if [claimant] stopped using drugs or alcohol." 20 C.F.R. § 416.935. Here, the ALJ determined that Cioppa's "alleged limitations are self imposed restrictions that are not well supported by the medical evidence and are inconsistent with some of her own actions." R. 14. Cioppa herself noted that her migraines cease once she stops using marijuana and cocaine. R. 320-21. Her statement, combined with the lack of objective medical evidence outlining the cause of her headaches, at least raise the suggestion that she would not have suffer from headaches without substance use.
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2. The ALJ's Consideration of Dr. Reimherr's and Dr. Awbrey's Opinion Evidence
Cioppa also argues that the ALJ failed to contact treating physicians Dr. Reimherr and Dr. Awbrey to clarify their opinions regarding Cioppa's residual functional capacity. Generally, an ALJ must contact a treating physician(s) if the evidence is "inadequate" for the ALJ to make a disability determination. 20 C.F.R. § 404.1512(e); see Soto-Cedeno v. Astrue, 2010 WL 2573085, at *2 (1st Cir. June 20, 2010) (stating that if the ALJ finds a physician's report to be inadequate, the ALJ "should obtain additional information 'first' by recontacting" the physician). Here, the ALJ's concern was not the adequacy of the basis of the two doctors' opinions, but whether the opinions were persuasive in light of those doctors' own treatment notes and the other objective medical evidence in the record, all of which the ALJ must review and take into account before making her decision, as statutorily required. 20 C.F.R. 404.1527(d); R. 8. Therefore, the ALJ had adequate evidence to evaluate Dr. Awbrey and Dr. Reimherr's opinions and was not required to recontact them.
Cioppa further contends that the ALJ disregarded Dr. Reimherr's and Dr. Awbrey's opinion evidence as ambiguous. Generally, an ALJ "must give more weight to the opinions from the claimant's treating physicians, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of the claimant's medical impairments." Rodriguez v. Astrue, 694 F.Supp.2d 36, 42 (D. Mass. 2010) (internal quotations omitted). However, this is not required if the treating physician's medical opinions are internally inconsistent or inconsistent with other substantial evidence in the record. See, e.g., Rooney v. Astrue, 2011 WL 6026908, at *9 (D. Mass. Dec. 5, 2011); Costa v. Astrue, 565 F.Supp.2d 265, 271 (D. Mass. 2008) (citing Rodriguez v. Sec'y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir. 1981)); Arruda v. Barnhart, 314 F.Supp.2d 52, 72 (D. Mass. 2004); Castro v. Barnhart, 198 F.Supp.2d 47, 54 (D. Mass. 2002).
a. Treating Physicians' Opinions Were Not Entitled to Controlling Weight
The opinions of Dr. Reimherr and Dr. Awbrey were both internally inconsistent and inconsistent with other substantial evidence in the record. Despite Dr. Reimherr's mental RFC assessment regarding Cioppa's preclusion from participating in competitive substantial gainful employment, R. 637, he noted that Cioppa had good social skills and was able to respond appropriately to changes in the work setting. R. 633-34. Dr. Reimherr only saw Cioppa on limited occasions. Id., 619-20. For the bulk of her psychiatric appointments, Cioppa met with Ms. Rosen, who never stated that she believed Cioppa was disabled. R. 280-348, 423-80, 621-32. Dr. Awbrey performed rotator cuff arthroscopy on Cioppa and met with her often before and after the surgery. R. 530-558 , 658-70. Although Dr. Awbrey remarked that Cioppa was "totally disabled" several times in his treatment notes, that conclusion is inconsistent with the results of MRIs that he conducted from 2004 to 2009, which revealed only minor strains and slight abnormalities in Cioppa's cervical spine, left thumb and left wrist. R. 554-60. Cioppa mentioned to Dr. Awbrey that she was not always in a state of pain, as she had "good and bad days." R. 552. Cioppa's own statements and the results of MRIs over the years are inconsistent with Dr. Awbrey's treatment notes that stated Cioppa was "totally disabled." R. 534, 538-39. Both Dr. Reimherr and Dr. Awbrey failed to present any objective medical opinions to support their conclusions, and therefore their opinions were properly accorded diminished probative weight.
The ALJ correctly noted that Cioppa could still manage well with routine tasks and activities of daily living, despite her medical ailments. R. 13, 16. Cioppa's own testimony suggests that she is not precluded from normal daily activities and experiences days without pain. R. 87. Moreover, the medical exams and treatment notes of other treating physicians such as Dr. Lee and Dr. Robinson, as well as nontreating physicians Dr. Goulding, and Dr. Kriston, reveal no objective medical evidence that would provide for a conclusion of disability, as suggested in Dr. Reimherr's and Dr. Awbrey's notes and opinions. R. 534, 538-9, 637. Dr. Lee noted that employment would be a good decision for Cioppa, as it would provide her with a sense of purpose. R. 384. During her numerous meetings with Cioppa, Ms. Rosen often gave Cioppa a GAF score of 55, indicative of only moderate symptoms. R. 619, 621, 625, 628. Dr. Goulding and Dr. Kriston determined that Cioppa could still find gainful employment in the national economy, despite her inability to do heavy lifting and upper extremity limitations. R. 373-80, 497.
In light of the consistent medical determinations and recommendations of other physicians, it was appropriate for the ALJ to accord Dr. Reimherr's and Dr. Awbrey's opinions less probative weight. The ALJ did "incorporate some of [Dr. Reimherr's] medical evidence . . . into the residual functional capacity," but he gave little weight to Dr. Reimherr's conclusory opinion of disability. R. 16. Similarly for Dr. Awbrey, the ALJ "considered his assessments," and where his conclusions aligned with the substantial evidence in the record, the ALJ incorporated his opinions into her RFC assessment as well. Id. Because the ALJ relied on substantial evidence and, in doing so, resolved any conflicts in the evidence, this Court defers to the ALJ's decision not to give Dr. Reimherr's and Dr. Awbrey's conclusions regarding disability controlling weight, citing their inconsistency with the record as a whole. See Konigsberg v. Astrue, 2010 WL 1794630, at *7 (D. Mass. Mar. 8, 2010) (citing Rodriguez Pagan v. Sec'y of Health & Human Servs., 819 F.2d 1, 3 (1st Cir. 1987)).
b. Weighing Medical Opinions of Treating Physicians Not Granted Controlling Weight
Where an ALJ decides not to afford a treating physician's opinion controlling weight, as is the case here, he or she must evaluate several factors in deciding how to weigh such a medical opinion: 1) the length of the treatment relationship and the frequency of examination; 2) the nature and extent of the treatment relationship; 3) the relevant evidence in support of the medical opinion; 4) the consistency of the medical opinion reflected in the record as a whole; 5) whether the medical provider is a specialist in the area in which he renders his opinions; and 6) other factors which tend to support or contradict the opinion. 20 C.F.R. § 404.1527(d). An ALJ may afford little probative value to a treating physician's opinion as long as he provides a reasonable explanation for doing so and the contrary finding is supported by substantial evidence. See Lee v. Astrue, 2011 WL 2748463, at *6 (D. Mass. July 14, 2011) (citing Shields v. Astrue, 2011 WL 1233105, at *7 (D. Mass. Mar. 30, 2011) and Monroe v. Barnhart, 471 F.Supp.2d 203, 211-12 (D. Mass. 2007)).
Both Dr. Reimherr and Dr. Awbrey concluded that Cioppa was disabled. R. 534, 637. An ALJ, however, is not obligated to accept "the conclusions of claimant's treating physicians on the ultimate issue of disability." Arroyo v. Sec'y of Health & Human Servs., 932 F.2d 82, 89 (1st Cir. 1991); see also Sitar v. Schweiker, 671 F.2d 19, 22 (1st Cir. 1982) (stating that a physician's conclusions are not binding on the ALJ).
Moreover, there was insufficient basis for these conclusions. First, the record shows that Dr. Reimherr only saw Cioppa on limited occasions, as she was mostly seen by Ms. Rosen. Compare R. 312, 619, 633-37, with R. 280-348, 423-80, 621-32. While treating source opinions are generally awarded more weight because they often provide a "longitudinal picture" of a claimant's impairment, see 20 C.F.R. § 404.1527(d)(2), because Dr. Reimherr's assessments are based on four interactions with Cioppa, they do not provide a "longitudinal picture" of Cioppa's mental impairments in the same manner that Dr. Lee's or Ms. Rosen's assessments do, especially given the extensive record of appointments Cioppa had with these physicians. Dr. Awbrey, on the other hand, did meet with Cioppa over a long period of time before and after her surgery. R. 529-53. However, no analysis or detail followed Dr. Awbrey's conclusory statements that Cioppa was "totally disabled," as his objective medical evidence and the MRIs do not substantiate his conclusion. R. 554-60. Therefore, Dr. Awbrey's objective medical evidence provides an apt longitudinal picture, but his conclusory opinions do not.
The ALJ emphasized that neither Dr. Reimherr nor Dr. Awbrey presented any relevant evidence in support of their medical conclusions. R. 16. Generally, the more relevant evidence a treating medical source presents, "particularly medical signs and laboratory findings," to support an opinion, or the better an explanation a source provides for an opinion, the more weight an ALJ should give that opinion. 20 C.F.R. § 404.1527(d)(3); Charon v. Astrue, 2011 WL 2268310, at *8 (D. Mass. June 6, 2011). As the ALJ mentioned, Dr. Reimherr stated that Cioppa had good social skills and could manage routine work. R. 16. The ALJ also stated that "the medical evidence of the record does not support" Dr. Awbrey's conclusion of disability. R. 14. Although Dr. Reimherr specializes in mental heath issues as a psychiatrist and Dr. Awbrey specializes in orthopedic medicine, without any objective medical evidence for Dr. Reimherr's or Dr. Awbrey's opinion regarding Cioppa's alleged disability, the ALJ found their opinions merited diminished weight.
Further, as this Court has already explained, Dr. Reimherr's and Dr. Awbrey's disability opinions are inconsistent with much of the record as a whole. Compare R. 637 (stating that Cioppa is precluded from substantial gainful employment and diagnosing her with bipolar disorder, post-traumatic stress disorder, and cannabis dependence) and R. 534, 542 (stating that Cioppa was totally disabled), with R. 373-78, 384, 497 619, 621, 628, 373-78 (various RFC assessments and physician opinions concluding that despite limitations, Cioppa could still function in a work setting). The record indicates that many of Cioppa's limitations may be self-imposed, remedied with the proper medication, social settings, therapy and termination of substance use. R. 321, 429, 438, 320, 621-22, 735. In sum, substantial evidence supports the ALJ's findings.
V. Conclusion
Based on the foregoing, the Commissioner's motion to affirm is GRANTED and Cioppa's motion to reverse or remand is DENIED.
So ordered.
Denise J. Casper
United States District Judge