Opinion
00 Civ. 8599
February 14, 2002
MEMORANDUM OPINION AND ORDER
The plaintiff, Pedro Rodriguez, brings this action pursuant to 42 U.S.C. § 405(g) to obtain judicial review of a determination of the Commissioner of Social Security (the "Commissioner"), denying his application for Disability Insurance Benefits ("disability insurance") and Supplemental Security Income ("SSI"). The parties consented to refer the case to me for final disposition under 28 U.S.C. § 636(c). The Commissioner has moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure, and, for the reasons that follow, the motion is granted.
Background
Mr. Rodriguez was fifty-five years old when he filed his application in November 1997. (Tr. 60). He was born in Puerto Rico in 1942 and moved to the contimental United States in 1961. (Tr. 29). Mr. Rodriguez has completed the eleventh grade and reads and speaks both English and Spanish. (Tr. 29-31). He worked as an accounting clerk for over twenty years and as a handyman for a brief period. (Tr. 31-32). He states that he became disabled in December 1993 and that he has not been gainfully employed since 1989. (Tr. 31-32, 61)
"Tr." indicates the Administrative Record (the "record") filed by the Commissioner.
A. Procedural History
On November 20, 1997, Mr. Rodriguez applied for disability insurance and SSI, alleging that he was unable to work because of a heart condition. (Tr. 60-61). When his application was denied, Mr. Rodriguez requested reconsideration, adding that he also suffered from back and leg pain. (Tr. 43). The application was again denied (Tr. 45), and Mr. Rodriguez requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. 49). That hearing was held on March 19, 1999, before Judge Joseph K. Rowe. (Tr. 26-41). Although Mr. Rodriguez was offered a Spanish language interpreter, he chose not to utilize this service. (Tr. 26-27). On May 19, 1999, the ALJ issued his decision holding that Mr. Rodriguez was not disabled and that he could perform work that "[does] not require frequent bending and climbing and lifting or carrying more than 10 pounds." (Tr. 11, 18-19). This determination became the final decision of the Commissioner when it was adopted by the Appeals Council on September 6, 2000. (Tr. 6). The plaintiff then filed the instant complaint on November 9, 2000.
B. Medical History
Mr. Rodriguez states that he has been disabled since December 15, 1993. However, the record indicates that he has received little medical treatment over the past several years. The only consistent ongoing treatment that he received was from the Morrisania Family Care Center ("Morrisania") over the course of a year in 1994. It is important to note that much of the Morrisania record is illegible. (Tr. 147-57). According to the record, Mr. Rodriguez's first treatment date after the onset of his alleged disability was February 3, 1994, when he had a physical examination at Morrisania during which he had no specific complaints. (Tr. 148). This record also reflects that Mr. Rodriguez had "spinal surgery in 1977." (Tr. 148). The results of Mr. Rodriguez's chest x-ray showed that his "[h]eart and pleural space [were] normal" and that his lungs, while "overly expanded," showed no "infiltrates or masses. (Tr. 154). The record concluded that these findings were compatible with chronic obstructive pulmonary disease. (Tr. 154). At his next appointment on February 5, 1994, Dr. Alan Diaz referred Mr. Rodriguez for follow-up treatment due to a positive PPD. (Tr. 149). On March 9, 1994, he returned to Morrisania for a follow-up visit; however, the notes relating to the results of the follow-up or any prescribed treatment are illegible. (Tr. 150). On May 6, 1994, Mr. Rodriguez returned for another follow-up, and the record reflects that his symptoms were better. (Tr. 151). Next, he was seen for a follow-up visit on August 4, 1994. (Tr. 152). A medical Release of Information form from Morrisania dated August 4, 1994, shows that Mr. Rodriguez was diagnosed with a positive PPD, chronic obstructive pulmonary disease, dyspepsia and an inguinal hernia. (Tr. 99). But the record is unclear as to the treatment prescribed for any of these conditions.
The pleural space is the area surrounding the pleural cavity [lungs]. Dorland's Illustrated Medical Dictionary ("Dorland's") 1402 (29th ed. 2000).
A positive PPD (purified protein derivative) indicates exposure to tuberculosis ("TB"). Dorland's 1890.
Dyspepsia is a digestive disorder that may be accompanied by pain. Kathleen Dredge White, Dyspepsia (Blue Cross Blue Shield of Massachusetts, Inc. 1999-2002) at http: //www.britannica.com/frm_redir.jsp?query=dyspepsiaredir=htt p://www.ahealthyme.com/article/gale/100084482isbol=0(last visited Feb. 6, 2002).
An inguinal hernia is a hernia located in the groin area.Dorland's 813, 899.
The next medical record documents that Mr. Rodriguez was treated at the Department of Social Services in San Juan, Puerto Rico on March 18, 1996, where he was diagnosed with herniated discs and lumbar radiculopathy. (Tr. 100). A letter from the Department of Veterans Affairs in Puerto Rico dated January 17, 1997, indicates that the plaintiff was diagnosed with degenerative joint disease, low back pain, and nephrolithiasis. (Tr. 103). However, the letter is unaccompanied by lab results or any other objective medical analysis to support the diagnosis. Further, it fails to document any prescribed treatment. (Tr. 103).
Radiculopathy is a disease of the nerve roots, which may cause pain. Dorland's 1511.
Nephrolithiasis is a condition marked by the presence of kidney stones. Dorland's 264, 1182.
On December 19, 1997, records from the Veterans Administration Hospital in New York, New York show that a general medical examination and a spinal examination were ordered for the plaintiff in order to determine his functional limitations. (Tr. 102). The results of the exam, which occurred on December 29, 1997, state that he had minimal functional impairment. (Tr. 131). This record also states that Mr. Rodriguez has complained of a back injury since the 1960's. (Tr. 130). However, the prescribed medical treatment consisted only of pain killers. (Tr. 130). Mr. Rodriguez informed the doctor that he had back surgery in the 1970's, which the doctor believed was probably related to a pilonidal cyst. (Tr. 130). The functional assessment portion of this record states that Mr. Rodriguez has "independence in activities of daily living and ambulates without [an] assistive device up to 5-10 blocks until [he] needs rest." (Tr. 131). It goes on to state that there is a normal range of motion of the L-S spine, painful at extreme flexion beyond 90 deg[rees] and bilateral lateral rotation (beyond 30 deg[rees])." (Tr. 131). Clinical tests results show, "small anterior spurs," but that the patient's "pelvis and bilateral . . . joints are [within normal limits]." (Tr. 131). Mr. Rodriguez's diagnosis was an "old spinal surgery for pilondial [sic] cyst; mechanical chronic low back pain syndrome with minimal functional impairment." (Tr. 131).
A pilonidal cyst is an abscess that occurs in the cleft between the buttocks. Graham Dark, The On-Line Medical Dictionary (Academic Medical Publishing and CancerWEB 1997-1999) at http://www.graylab.ac.uk/cgi-bin/omd? pilonidal+cyst (last visited Feb. 6, 2002).
Nearly six months later, on July 10, 1998, Mr. Rodriguez was seen at the New York Diagnostic Centers, Inc. (Tr. 112). Although the record indicates that he was slow getting on the exam table, Dr. Antonio DeLeon stated that there was "no back tenderness or muscle spasm," and that his heart tones were regular. (Tr. 113). There was no indication by Dr. DeLeon that Mr. Rodriguez's pace in getting on the examination table was medically significant or substantially relevant for assessment purposes. The record also shows that the patient was coherent and that there was no evidence of "motor, sensory or cerebellar dysfunction." (Tr. 113). During the same appointment chest x-rays were taken by Dr. Allan Brook, the results of which showed over-expanded lungs but a normal heart. (Tr. 119). While x-rays did show a marked end-plate and facet osteoarthritis, there was no evidence of compression deformity. (Tr. 119). Dr. DeLeon noted that his prognosis was "fair," and his opinion was that Mr. Rodriguez was capable of working. Specifically he found that the plaintiff could sit without limitation, but that his standing and walking capacities were mildly limited due to back pain and shortness of breath. (Tr. 114)
Medical records from Bellevue Hospital dated March 11, 1999, show that Mr. Rodriguez was seen by Dr. Soumya Reddy in connection with his back. (Tr. 144). The plaintiff complained that he could not lift more than five pounds or sit for more than thirty minutes at a time. (Tr. 141-42). Dr. Reddy's report did not confirm the plaintiff's claim that he was unable to lift more than five pounds. (Tr. 141). Instead, she noted that because the patient had no prior lab work or radiologic tests done at Bellevue, there was "insufficient data" to confirm Mr. Rodriguez's statement that he was unable to function due to pain. (Tr. 144). The doctor further indicated in the record that the plaintiff "appears able to walk [without] difficulty." (Tr. 144). The record also states that Mr. Rodriguez was referred for rehabilitation. (Tr. 144)
Discussion
A. Standard of Review
The scope of review of an SSI and disability insurance determination involves two levels of inquiry. First, the court reviews the Commissioner's decision to determine whether the Commissioner applied the correct legal standard. See Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999); Tejada v. Apfel, 167 F.3d 770, 773 (2d Cir. 1999); Lugo v. Chater, 932 F. Supp. 497, 500 (S.D.N.Y. 1996). Second, the court must decide whether the AU's decision was supported by substantial evidence. See Rosa, 168 F.3d at 77; Brown v. Apfel, 174 F.3d 59, 61 (2d Cir. 1999); Balsamo v. Chater, 142 F.3d 75, 79 (2d Cir. 1998); Lugo, 932 F. Supp. at 500; see also 42 U.S.C. § 405 (g) (providing that "[t]he findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive"). Substantial evidence is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consolidated Edison Co. v. National Labor Relations Board, 305 U.S. 197, 229 (1938));see Rosa, 168 F.3d at 77, Pratts v. Chater, 94 F.3d 34, 37 (2d Cir. 1996). "[T]o determine whether the findings are supported by substantial evidence, the reviewing court is required to examine the entire record, including contradictory evidence[.]" Brown, 174 F.3d at 62 (quotation and citation omitted).
In addition, a reviewing court must be satisfied that the claimant had "a full hearing under the [Commissioner's] regulations and in accordance with the beneficent purposes of the Act." Echevarria v. Secretary of Health and Human Services, 685 F.2d 751, 755 (2d Cir. 1982) (quoting and citation omitted). Accordingly, the AU must have issued a written decision explaining the reasons for his or her findings. 20 C.F.R. § 404.953(a). ""It is self-evident that a determination by the [Commissioner] must contain a sufficient explanation of [her] reasoning to permit the reviewing court to judge the adequacy of [her] conclusions.'" Lugo, 932 F. Supp. at 501 (quoting Rivera v. Sullivan, 771 F. Supp. 1339, 1354 (S.D.N.Y. 1991)); see also White v. Secretary of Health and Human Services, 910 F.2d 64, 65 (2d Cir. 1990).
A claimant seeking disability benefits under the Social Security Act is considered disabled if he is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment 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 twelve months." 42 U.S.C. § 1382c(a)(3)(A). In order to determine whether a claimant is disabled, the AU follows a five-step process outlined in regulations promulgated under the Social Security Act. See 20 C.F.R. § 416.920; see also Curry v. Apfel, 209 F.3d 117, 122 (2d Cir. 2000) (describing five-step process in parallel statutory provision for disability benefits); Rosa, 168 F.3d at 77 (same); Balsamo, 142 F.3d at 79-80 (same). First, the ALJ determines if the claimant is currently engaged in substantial gainful activity. See 20 C.F.R. § 416.920(b). If he is not, the AU must decide if the claimant has a severe impairment, one that "significantly limits [the claimant's] physical or mental ability to do basic work activities." 20 C.F.R. § 416.920(c). If the claimant's impairment is severe and is either listed in 20 C.F.R. Part 404, Subpt. P, App. 1, or is equivalent to a listed impairment, the claimant must automatically be found disabled without considering vocational factors such as age, education, and work experience. See 20 C.F.R. § 416.920(d). If the claimant's impairment is severe but is not listed or equal to a listed impairment, a finding of not disabled is directed if his residual functional capacity permits him to do the work he did in the past. See 20 C.F.R. § 416.920 (e). If the claimant is unable to perform his past work, the ALJ must decide if there is other available work that the claimant is able to perform based on his residual functional capacity, age, education, and past work. See 20 C.F.R. § 404.1520 (f)(1).
The claimant bears the burden of proof with respect to the first four steps in the analysis. If the claimant demonstrates an inability to perform past work, the burden shifts to the Commissioner to show that there exists other work that the claimant can perform. See Rosa, 168 F.3d at 77, Perez v. Chater, 77 F.3d 41, 46 (2d Cir. 1996)
B. The ALJ's Decision
The ALJ determined that Mr. Rodriguez was not disabled, stating that "[Mr. Rodriguez's] receipt of medical treatment is neither intense or frequent and for prolonged periods nil." (Tr. 17). The ALJ further stated that "[h]is complaint of totally disabling back pain is not supported by objective clinical findings, not commensurate with the overall receipt of medical treatment received and not found fully credible." (Tr. 17). The ALJ concluded that Mr. Rodriguez retained the residual functional capacity to perform the work that he had previously done as an accounting clerk. (Tr. 18). He found that the plaintiff's medical records did not reflect that he was ever incapacitated for a period of twelve consecutive months, as required by 20 C.F.R. § 404.1509. (Tr. 18). The ALJ also found that Mr. Rodriguez had not "engaged in substantial gainful activity since April 10, 1989" and that the "evidence fail[ed] to establish the presence of any physical or mental impairment that would limit his exertional or non-exertional capacity to perform basic work related functions." (Tr. 15). The ALJ gave substantial weight to the lack of consistent medical treatment during the period in which the plaintiff claimed he was disabled.
C. Merits
The medical evidence supports the ALJ's finding that Mr. Rodriguez is able to perform the job functions he had previously performed as an accounting clerk and that his statements concerning his pain and his inability to work were not credible. Furthermore, the record supports the ALJ's finding that he is not disabled.
1. Medical Evidence
Although Mr. Rodriguez has provided a number of medical documents and records, the data contained within them are at times subjective recitations of the plaintiff's alleged disability and are unsupported by clinical findings. At other times the record reflects that, based on medical opinion, Mr. Rodriguez is not disabled and is capable of performing past related work activities.
While he claims that his lower back pain, heart condition, and liver problems prevent him from working, the administrative record suggests otherwise. Between December 1993, the onset of the plaintiff's alleged disability, and March 1999, the date of his administrative hearing, the plaintiff was seen for medical treatment what appears to be, according to the record, only eight times.
The plaintiff first asserted liver disease as a disabling condition in May 1998. (Tr. 79). The record does not appear to contain any evidence of treatment with respect to any liver condition.
In 1994, the year following the onset of Mr. Rodriguez's alleged disability, he was seen a number of times at Morrisania. However, as previously noted, much of this record is grossly illegible. The parts that are legible indicate that Mr. Rodriguez had "no specific complaints" at his initial appointment on February 3, 1994. The following day Dr. Diaz referred Mr. Rodriguez for follow-up treatment after test results showed a positive PPD from exposure to tuberculosis within six months prior to the test. (Tr. 149). Mr. Rodriguez was then seen for several additional follow-up visits which appear to have been for TB treatments only. (Tr. 150 52).
There are no medical records for 1995, and the only record of medical treatment in 1996 is a document from the Department of Social Services in Puerto Rico stating that Mr. Rodriguez is totally disabled. (Tr. 100). However, there are no clinical records to support such a conclusion. In 1997, treatment records showed a diagnosis of "mechanical chronic low back pain," but there is no record of any follow-up treatment. (Tr. 131). In 1998, Mr. Rodriguez was seen by Dr. Brook, who acknowledged that tests showed a "marked end-plate and facet osteoarthritis," but he says nothing about required follow-up treatment. (Tr. 119).
In addition, there are records that suggest that Mr. Rodriguez is capable of performing the work he previously performed as an accounting clerk. Veterans Administration Hospital records from 1997 expressly state that Mr. Rodriguez, despite being diagnosed with mechanical chronic low back pain syndrome, had only "minimal functional impairment." (Tr. 131). Then in 1998, Dr. DeLeon stated that Mr. Rodriguez's prognosis was "fair" and that he was capable of working. (Tr. 114). Finally, in 1999, Dr. Reddy stated that she was unable to confirm Mr. Rodriguez's complaints of severe pain because there were no clinical tests for her to view. (Tr. 144).
2. Mr. Rodriguez's Testimony
The remaining evidence of disability consists solely of Mr. Rodriguez's testimony that he is, and has been, in such pain that he cannot work at all. However, the ALJ stated that Mr. Rodriguez's testimony is "not found fully credible." (Tr. 17). The ALJ may make credibility determinations,Tejada, 167 F.3d at 775 76, and must do so where "there is conflicting evidence about a claimant's pain[.]" Snell v. Apfel, 177 F.3d 128, 135 (2d Cir. 1999); see also Pascariello v. Heckler, 621 F. Supp. 1032, 1036 (S.D.N.Y. 1985) (after considering objective medical evidence, claimant's demeanor and other indicia of credibility, the ALJ may discredit claimant's subjective estimation of degree of impairment). An ALJ's determination as to the credibility of a claimant's subjective complaints of pain must be accepted by the reviewing court unless it is clearly erroneous. See Aponte v. Secretary of Health and Human Services, 728 F.2d 588, 591 (2d Cir. 1984; Centano v. Apfel, 73 F. Supp.2d 333, 338 (S.D.N.Y. 1999). Here, the ALJ committed no error. The plaintiff has provided no objective medical evidence showing a condition that reasonably causes disabling pain. Moreover, there is no indication that pain will interfere with his ability to perform the duties of an accounting clerk. Accordingly, the ALJ's conclusion that Mr. Rodriguez has the residual functional capacity to perform past relevant work activities is well-founded.
Conclusion
The Commissioner's decision denying the plaintiff SSI and disability insurance benefits is supported by substantial evidence. Accordingly, the Commissioner's motion is granted and Clerk of Court shall enter judgment dismissing the complaint.
SO ORDERED.