Opinion
IP 00-1812-C-T/F
March 12, 2002
ENTRY REVIEWING COMMISSIONER'S DECISION
This Entry is a matter of public record and is being made available to the public on the court's web site, but it is not intended for commercial publication either electronically or in paper form. Although the ruling or rulings in this Entry will govern the case presently before this court, this court does not consider the discussion in this Entry to be sufficiently novel or instructive to justify commercial publication or the subsequent citation of it in other proceedings.
Plaintiff requests judicial review, under 42 U.S.C. § 405(g), of the final decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff of Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB"). The court rules as follows.
I. Background
A. Procedural
Plaintiff, James A. Patton, filed an application for DIB and SSI on October 21, 1997, claiming peptic ulcer and heart condition rendered him disabled since June 15, 1997. (R. at 159, 164.) These applications were denied initially on February 10, 1998, and on reconsideration on May 13, 1998. (R. at 134, 140.) On June 3, 1998, Plaintiff requested a hearing. Plaintiff appeared with counsel (Attorney T. Reg Hesselgrave) in proceedings before Administrative Law Judge ("ALJ") Manuel J. Carde on January 12, 1999 and March 2, 1999 (R. at 43, 128). During these proceedings, Plaintiff alleged that a cervical spine disorder, as well as the previously claimed heart condition rendered him disabled, but made no mention of the peptic ulcer originally claimed. From these hearings, the ALJ found that Plaintiff had the residual functional capacity ("RFC") "for a full range of light work." (R. at 19.) On April 30, 1999, the ALJ issued a decision finding Plaintiff not eligible for SSI or DIB. (R. at 20.) After Plaintiff's subsequent appeal to the Appeals Council was denied, making it the final decision of the Commissioner, Plaintiff brought this action seeking judicial review of the decision pursuant to 42 U.S.C. § 405(g).
B. General
Plaintiff was born on November 27, 1949, and was forty-nine (49) years of age at the time of the proceeding before the ALJ. He has an eleventh grade education and last worked in June 1997 performing banquet setup at a hotel. (R. at 67.)
C. Medical Evidence
In June of 1996, Plaintiff underwent angioplasty (R. at 206) after suffering a myocardial infarction (heart attack), but returned to work approximately one month later (R. at 70). Following a second hospitalization due to chest pains (which were found not to be due to myocardial infarction or unstable angina pectoris) in April 1997 (R. at 192), Plaintiff again returned to work (R. at 71).
Plaintiff quit working in June of 1997 (R. at 67) purportedly due to radiating pain from his neck to his left shoulder and arm (R. at 85-86). However, it was not until August 22, 1997, that Plaintiff complained of the pain to his primary care physician, Dr. Gregory Gramelspacher. (R. at 189, 281.) A reduction in range of motion was noted, but no effusion (Id.).
On November 18, 1997, a consultative examination revealed that plaintiff possessed a normal range of motion in all joints (R. at 243), as well as normal strength, reflexes, and manual dexterity (R. at 240-43). The examining physician, Dr. Jacobs, diagnosed Plaintiff with stable angina but stated that he could perform work not involving heavy exertion. (R. at 242.)
On December 14, 1997, Dr. A. Landwehr, a State Agency medical consultant, reviewed Plaintiff's previous medical records and found Plaintiff to be capable of frequently lifting ten pounds, standing for six hours during an eight hour day, sitting for six hours during an eight hour day, and occasionally lifting twenty pounds (R. at 245).
On December 29, 1997, Plaintiff underwent a cardiac stress test which was terminated after two minutes and fifteen seconds due to fatigue and bilateral claudication (numbness in the legs) (R. at 252-53).
In March 1998, Plaintiff underwent another consultative examination in which Dr. Vera L. Nelson, a clinical physician, noted Plaintiff's complaints of occasional chest and arm pain that were alleviated with the administration of nitroglycerine pills. (R. at 263.) Dr. Nelson stated that Plaintiff seemed "confused" in his reports of angina pain radiating down his leg (which she noted was anatomically impossible), and in Plaintiff's belief that the angina pain limited the strength and mobility of his left arm (R. at 266). Finally, Dr. Nelson noted that Plaintiff was not entirely cooperative with the exam, and that she believed Plaintiff was "deliberately trying to limit his capabilities" during the exam (Id.).
Plaintiff underwent a consultative psychological examination on April 1, 1998. Dr. Jerome Modlik, the psychologist performing the examination, reported that Plaintiff was "clearly malingering cognitive and psychiatric symptoms" and that he was "attempting to present himself as a total invalid who is really essentially demented." (R. at 273.)
On April 7, 1998, Plaintiff visited with his primary care physician, Dr. Gregory Gramelspacher, who ordered a cervical MRI (magnetic resonance imagery) in response to Plaintiff's continued complaint of radiating pain in his left shoulder and arm (R. at 279). Dr. Gramelspacher noted that Plaintiff had missed several appointments and was not taking his medication, but was experiencing no chest discomfort and doubted he had angina. (R. at 275, 279.)
In August 1998, a stress test administered to determine Plaintiff's ability to undergo fusion surgery for his cervical spine was cut short due to onset of chest pain, but the doctor found no indication of ischemia (deficiency of blood supply to the heart). (R. at 318.)
Utilizing this information, Dr. Carl Rouch, a member of the cardiology staff at Wishard Memorial Hospital, later cleared Plaintiff as an acceptable candidate for spinal fusion surgery. (R. at 314.)
After undergoing the spinal fusion surgery in December 1998, Plaintiff reported improvement in the condition of his left arm, but that he continued to have back and neck pain. (R. at 304.) On January 20, 1999, a neurosurgery resident at Wishard reported that Plaintiff walked with a stiff neck, exhibited reduced flexibility and rotation, and complained of back soreness and radiating pain to both arms. However, the resident noted that Plaintiff exhibited full strength in both arms, with the exception of slight weakness in the left triceps. (R. at 333.)
Dr. Richard A. Hutson, an orthopedic surgeon, testified as an expert witness at the March 1999 hearing before the ALJ. Dr. Hutson testified that while Plaintiff's vertebrogenic disorder might have originated eight to nine months earlier, it was not documented through testing until April 1998 (R. at 118-21). As well, Dr. Hutson noted that the documentation of the disorder did not necessarily indicate a disabling condition at its onset (R. at 121) and that Plaintiff's ability to use his full range of motion in his left shoulder indicated that he was not experiencing pain prior to April 1998 (R. at 123-24). Lastly, Dr. Hutson explained that Plaintiff should refrain from "heavier" work for six months following his surgery, but that he was capable of performing light or sedentary work at the time of the hearing (R. at 125).
II. Discussion
A. Standard of Review
The Social Security Act requires a reviewing court to accept the ALJ's findings of fact as conclusive if they are supported by substantial evidence and there has been no error of law. Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). Substantial evidence refers to relevant evidence that a reasonable mind could accept as adequate to support a conclusion. Id.; Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001). While a reviewing court will review the entire record to determine if there is relevant evidence adequate to support the conclusion of the ALJ, it is improper for the court to decide facts anew, re-weigh the evidence, or substitute its judgment for that of the ALJ. Kepple v. Massanari, 268 F.3d 513, 516 (7th Cir. 2001).
B. Analysis
When determining disability, the ALJ performs a five-step inquiry. Dixon v. Massanari, 270 F.3d at 1176 (summarizing the agency regulations set forth in 20 C.F.R. § 404.1520). In making his decision, the ALJ must articulate his analysis of that evidence and "build an accurate and logical bridge from the evidence to [his] conclusion." Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000). While an ALJ may not ignore an entire line of evidence that is contrary to his findings he also "need not provide a complete written evaluation of every piece of testimony and evidence," Diaz v. Chater, 55 F.3d 300, 307-08 (7th Cir. 1995); see also Zurawski v. Halter 245 F.3d 881, 888 (7th Cir. 2001); Henderson v. Apfel, 179 F.3d 507, 514 (7th Cir. 1999).
Plaintiff challenges the decision at step five of the analysis, claiming that (1) the ALJ's decision he "has the residual functional capacity for light work" is either unsupported by substantial evidence or not reasonably articulated. He further contends (2) that the ALJ's assessment of Plaintiff's credibility was wrong, and (3) was remiss in his duty to fully develop the record. The Court will address each of these contentions in turn.
1. Basis of Substantial Evidence; Articulation of Reasoning
a) Radiating Neck Pain; Weakness of the Left Arm
Plaintiff argues that the ALJ erred in concluding that his physical impairments were not severe. Plaintiff asserts that there was not a substantial basis for finding that Plaintiff is capable of light work since his testimony of intense pain and weakness in his left arm were credible and corroborated by orthopedic evidence in the form of testimony at the hearing.
Plaintiff further argues that the ALJ failed to consider the spinal fusion surgery in weighing his impairments, and that proper consideration of this evidence should lead to a finding that Plaintiff is disabled.
The ALJ did note that Plaintiff's spinal fusion surgery (R. at 17) created an objective medical basis for complaints of pain in the shoulder and left arm, but properly found that medical evaluations consistently showed the pain was not debilitating to the extent claimed by Plaintiff. Indeed, the very orthopedic testimony Plaintiff relies upon as proof of disablement is accompanied by a statement implying that he is capable of light or sedentary work even during the six months following the spinal fusion surgery (R. at 125). In fact, when the orthopedic surgeon was asked whether Plaintiff's description of his pain was consistent with someone undergoing a cervical spinal fusion, he stated: "I would expect him to have that kind of pain as the tissue, the soft tissues were healing right after the surgery, but I would not expect that this patient would need Tylenol with codeine . . . at this point in time." (R. at 126.) While Plaintiff claimed that he had to take two Tylenol 3 with codeine each day in order to cope with the pain, the orthopedic surgeon's testimony weighs against finding Plaintiff credible. Furthermore, the testimony of orthopedic surgeon indicated that while the degenerative cervical spine condition may have been present at an earlier time, it was not necessarily disabling at onset. (R. at 119-23.)
Plaintiff stated he was able to walk only four blocks, stand for fifteen minutes, and sit for twenty minutes; however physical evaluations performed by medical professionals routinely found Plaintiff to be capable of performing light work. For example, in November 1997, Dr. Jacobs found Plaintiff capable of work not involving heavy exertion (R. at 240-43). In April 1998, Dr. Bastnagel, a State Agency medical consultant found that the plaintiff was capable of light work (R. at 296). Furthermore, Plaintiff's own testimony revealed that he was physically capable of standing, sitting and walking far more than he claimed (R. at 92-98). As such, there was substantial evidence to find that the Plaintiff's vertebrogenic condition did not prevent him from performing light work.
b) Cardiac Condition
Plaintiff further contends that the ALJ erred in finding that his cardiac condition was not disabling. He argues that if the appropriate weight was given to the cardiac stress tests, he would be considered disabled.
However, the ALJ had substantial evidence to find that the Plaintiff's cardiac condition did not prevent him from the demands of light work. While Plaintiff was hospitalized for chest pain in April 1997, the Wishard cardiology department "ruled out the occurance [sic] of an acute MI [myocardial infarction] or unstable angina based on the results fo the EKG, cardiac markers, lactate, and ECHO which were all negative and/or normal. (R. at 192.) On November 18, 1997, Dr. Jacobs concluded that plaintiff could perform work that did not involve heavy exertion (R. at 240-43), and opined that Plaintiff had stable angina (R. at 242). As well, Plaintiff's own physician stated that Plaintiff was not experiencing any chest pain (R. at 275) in April of 1998, and doubted that Plaintiff was experiencing angina (R. at 279). Finally, Dr. Carl Rouch, the attending doctor at Wishard, noted that the stress test results (indicating no ischemia), coupled with the Plaintiff's rare chest pains qualified him as a low-risk surgery candidate. (R. at 314.) Thus, the ALJ had substantial medical evidence to conclude that Plaintiff's cardiac condition did not prevent him from performing light work.
Moreover, the ALJ reasonably articulated his weighing of the evidence in reaching his conclusion. While the ALJ need not provide a complete written evaluation of every piece of testimony and evidence, the rejection of Plaintiff's claim is consistent with the specific finding that Plaintiff's claims of residual capacity and subjective complaints of pain were not credible. Diaz, 55 F.3d at 308. As such, the findings and conclusions of the ALJ were reasonably articulated and based on substantial evidence.
2. Plaintiff's Credibility
Plaintiff contends that the ALJ failed to give proper weight to the testimony of the Plaintiff, claiming that an objective review of the orthopedic testimony will find the ALJ's credibility findings were based on a gross mischaracterization of the evidence presented.
The credibility determinations made by an ALJ generally will not be overturned unless they are "patently wrong." Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000).
However, the ALJ's credibility determination "must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual's statements and the reasons for that weight." Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001). In making credibility decisions regarding the claimant's subjective allegations of pain, the ALJ must weigh the claimant's complaints with the medical evidence as well as any other evidentiary indicators. Caviness v. Apfel, 4 F. Supp.2d 813, 819 (S.D.Ind. 1998). In this weighing process, the ALJ must also consider:
(1) The claimant's daily activities;
(2) Location, duration, frequency, and intensity of pain or other symptoms;
(3) Precipitating and aggravating factors;
(4) Type, dosage, effectiveness, and side effects of any medication;
(5) Treatment, other than medication, for relief of pain or other symptoms;
(6) Other measures taken to relieve pain or other symptoms;
(7) Other factors concerning functional limitations due to pain or other symptoms.20 C.F.R. § 404.1529(c)(3), 416.929(c)(3).
In this case, the ALJ explained that the pain and limiting effects described by Plaintiff were inconsistent with several specific portions of the record, concluding that the Plaintiff is not credible and his complaints were excessive in light of the objective medical evidence. The ALJ noted more than four sources that contradict Plaintiff's characterization of his physical condition: his primary care physician, Dr. Gramelspacher; the August 1998 stress test showing no ischemia; claimant's daily living activities; and claimant's failure to attend doctor appointments and regularly take his medication. (R. at 18-19.) In addition, the ALJ cited opinions from Dr. Jerome Modlik, a consulting psychologist, and Dr. Vera Nelson, a consulting physician, who both noted that Plaintiff was not cooperative and intentionally underperformed during examinations. (R. at 18.) As such, the ALJ indicated appropriate reasons to find Plaintiff's credibility lacking.
Plaintiff asserts that the ALJ mischaracterized the medical testimony and records in order to find Plaintiff lacking in credibility. Specifically, Plaintiff points to the ALJ's use of medical evidence regarding Plaintiff's ability to perform lower lumbar exercises and walk properly as inappropriate in determining whether Plaintiff's claims of pain in his cervical spine were exaggerated. Citing Caviness v. Apfel, Plaintiff urges the court to set aside the ALJ's credibility determination. 4. F. Supp.2d 813, 819 (S.D.Ind. 1998) (holding that the ALJ's gross mischaracterization of the record, including omission of several relevant facts favorable to the claimant, gave good reason to set aside decision).
In Caviness, the court held that ALJ improperly discredited the claimant's complaints of pain based upon her failure to seek medical treatment, her ability to attend Ball State University as a full time student, and her ability to visit with friends and family. Id. at 819-23. The court held that it was inappropriate to completely ignore an entire line of evidence that suggested that she did not seek care only because she was in severe financial need, while basing a credibility conclusion on her lack of medical treatment. Id. at 821. Similarly, that ALJ refused to acknowledge that the claimant only took two credit hours on campus (which she frequently missed due to medical problems), completing the rest of the classes by correspondence. Id. 821-22. The ALJ further ignored the claimant's work history, which indicated that she lost many jobs as a proof reader due to health-related absenteeism. Id. at 822. As well, the ALJ neglected to note that most visitation with friends and family occurred in her own home. Id. While the claimant's severe lung infections were episodic in nature, the ALJ simply focused upon the claimant's capabilities when she was at her healthiest, without considering the fact that the claimant was routinely incapacitated by the lung infections when they would "flare up." Id. As such, the ALJ in Caviness grossly mischaracterized and ignored evidence, and failed to demonstrate consideration of evidence in the record in his decision to deny benefits.
Such is not the case here. The ALJ did not ignore objective evidence that would lend credibility to the Plaintiff's claims of pain and debilitation. The ALJ refers to Plaintiff's capability to perform a straight leg raise test and heel toe walk to indicate that Plaintiff was not credible in stating that he could not stand for fifteen minutes or sit for more than twenty minutes. The ALJ also based his conclusions of credibility and disability upon opinions of multiple physicians, including Plaintiff's primary care physician. Even if the straight leg raise test and heel toe walk did not indicate Plaintiff's lack of credibility, the ALJ indicated several other inconsistencies in the record that would support a finding that Plaintiff was not credible. In fact, Plaintiff has failed to raise any corroborating medical testimony that would rehabilitate his credibility. Given the ALJ's explanation, and an accurate reflection of the record, the credibility determination cannot be considered "patently wrong."
3. Duty to Develop the Record; Recontact Treating Physician
Plaintiff contends that the ALJ failed to adequately develop the record by not contacting Plaintiff's treating physicians prior to the issuance of the denial (Br. at 4). He also contends that the ALJ refused Dr. Vera Nelson's March 1998 recommendation to schedule "another independent exam or confirmation by his primary care physician" because Plaintiff was "deliberately trying to limit his capabilities during this exam." (R. at 266.) Plaintiff asserts that "neither Social Security nor the ALJ ordered another independent exam, or recontacted Mr. Patton's treating physician for a detailed assessment to determine his capabilities," which is in violation of the ALJ's duty to develop the record. (Appellant's Br. at 6.)
The ALJ does have a duty to fully develop the record. Luna v. Shalala, 22 F.3d 687, 692 (7th Cir. 1994). However, in determining how much evidence gathering was necessary, the reviewing court must respect the reasoned judgment of the ALJ. Kendrick v. Shalala, 998 F.2d 455, 458 (7th Cir. 1993). With respect to contacting physicians, the ALJ is required to seek "additional evidence or clarification" from a medical source only when the information received is inadequate to determine whether a claimant is disabled or when the medical source report contains a conflict or ambiguity that must be resolved. 20 C.F.R. § 404.1512(e); Pigram v. Barnhart, No. 00-C-7163, 2002 WL 187500, at *8 (N.D.Ill. Feb. 6, 2002).
Plaintiff's argument is without merit. 20 C.F.R. § 404.1512(e) does not require the ALJ to recontact the claimant's primary care physician unless reports sent by him contained conflicts or ambiguities, incomplete information, or are not based on "medically acceptable clinical and laboratory diagnostic techniques." Plaintiff does not contend that his primary care physician entered incomplete reports or relied upon questionable diagnostic techniques. Thus, the ALJ was not required to recontact Plaintiff's primary care physician.
Although the ALJ was not required to do so, he did recontact the Plaintiff's primary care physician at the recommendation of Dr. Vera Nelson. A cursory review of the record reveals that Dr. Gramelspacher, Plaintiff's primary care physician, submitted his own assessment at the request of the Commissioner less than one month after the consultative examination performed by Dr. Nelson on March 28, 1998. (R. at 275-85.) This assessment, dated April 17, 1998, was based upon another examination of Plaintiff which was performed either on April 7 or April 17, 1998. (R. at 275, 279.)
Dr. Gregory Gramelspacher's report, written on April 17, 1998, states that the patient (Plaintiff) was last examined on April 17, but the accompanying charts indicate that the last patient visit occurred on April 7, 1998. Regardless of the last date of visit, the fact remains that the primary care physician was recontacted.
The assessment submitted by Dr. Gramelspacher did not provide any revelations which would benefit Plaintiff's claim. Rather, the report differed from Dr. Nelson's medical examination in two significant ways: (1) it explained the source of Plaintiff's shoulder and arm pain (R. at 275), and (2) it confirmed Dr. Nelson's suspicion that Plaintiff was intentionally misrepresenting his capabilities. Dr. Nelson's consultative assessment includes the Plaintiff's reported history of suffering two myocardial infarctions. Plaintiff also claimed that he experienced chest pains that required nitroglycerin treatment at least one time per week. (R. at 263.) However, Dr. Gramelspacher's report, which was conducted less than three weeks later, reveals that Plaintiff was not suffering from chest discomfort, and that Plaintiff's medical history includes only one myocardial infarction. (R. at 275.)
Therefore, the primary care physician's assessment differed from the consultative examination only to the extent that it verified Dr. Nelson's suspicions that Plaintiff was intentionally misrepresenting his capabilities.
Furthermore, the record indicates that the ALJ gave consideration to the report submitted by Dr. Gramelspacher. The ALJ cited this report in finding that neither Plaintiff's cardiac condition nor side affects from his medications restricted him from performing light work. (R. at 18.) As such, Plaintiff's contention that his primary care physician was not recontacted does not accurately reflect the record.
The decision of the ALJ in this case is supported by substantial evidence and a well-developed record. As such, this court will not disturb the findings and conclusions of the ALJ.
III. Conclusion
IT IS THEREFORE ORDERED that the decision of the Commissioner in this case is AFFIRMED.