Opinion
Civil Action 8:20-cv-03586-TLW-JDA
11-05-2021
Sharon Schronce, Plaintiff, v. Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION OF MAGISTRATE JUDGE
Jacquelyn D. Austin, United States Magistrate Judge.
This matter is before the Court for a Report and Recommendation pursuant to Local Civil Rule 73.02(B)(2)(a), D.S.C., and 28 U.S.C. § 636(b)(1)(B). Plaintiff brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the Commissioner of Social Security (“the Commissioner”), denying Plaintiff's claims for disability insurance benefits (“DIB”) and supplemental security income (“SSI”).For the reasons set forth below, it is recommended that the decision of the Commissioner be affirmed.
A Report and Recommendation is being filed in this case, in which one or both parties declined to consent to disposition by a magistrate judge.
Section 1383(c)(3) provides, “The final determination of the Commissioner of Social Security after a hearing under paragraph (1) shall be subject to judicial review as provided in section 405(g) of this title to the same extent as the Commissioner's final determinations under section 405 of this title.” 42 U.S.C. § 1383(c)(3).
PROCEDURAL HISTORY
In January 2018, Plaintiff filed applications for DIB and SSI, alleging an onset of disability date of September 1, 2012. [R. 196-214.] The claims were denied initially and on reconsideration by the Social Security Administration (“the Administration”). [R. 64-130, 133-39.] Plaintiff requested a hearing before an administrative law judge (“ALJ”) and on August 8, 2019, ALJ Jerry Peace conducted a de novo hearing on Plaintiff's claims. [R. 37-61.]
The ALJ issued a decision on August 30, 2019, finding Plaintiff not disabled under the Social Security Act (the “Act”). [R. 15-31.] At Step 1, the ALJ found Plaintiff met the insured status requirements of the Act through December 31, 2015, and had not engaged in substantial gainful activity since September 1, 2012, the alleged onset date. [R. 20, Findings 1 & 2.] At Step 2, the ALJ found Plaintiff had the following severe impairments: degenerative disc disease; ischemic heart disease with cardiomyopathy; diabetes with neuropathy; and obesity. [R. 20, Finding 3.] At Step 3, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. [R. 20-21, Finding 4.]
The five-step sequential analysis used to evaluate disability claims is discussed in the Applicable Law section, infra.
Before addressing Step 4, Plaintiff's ability to perform her past relevant work, the ALJ found Plaintiff retained the following residual functional capacity (“RFC”):
I find that the claimant has the [RFC] to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b). I specifically find that the claimant can lift and/or carry 20 pounds occasionally and 10 pounds frequently. The claimant can sit and stand and/or walk, with normal breaks, for 6 hours each in an 8-hour workday. The claimant can never climb ladders, ropes or scaffolds. She can occasionally climb ramps or stairs. She can occasionally balance, stoop, crouch, kneel or crawl. She is limited to no more than frequent use of moving machinery or exposure to unprotected heights.
[R. 22, Finding 5.] Based on this RFC finding, the ALJ determined at Step 4 that Plaintiff was able to perform her past relevant work. [R. 25-26, Finding 6]. Thus, the ALJ found that Plaintiff had not been under a disability from September 1, 2012, through the date of the decision. [R. 26, Finding 7.]
Plaintiff requested Appeals Council review of the ALJ's decision but the Appeals Council declined review. [R. 1-7.] Plaintiff filed the instant request for review in this Court on October 13, 2020. [Doc. 1.]
THE PARTIES' POSITIONS
Plaintiff contends the ALJ's decision is not supported by substantial evidence and should be reversed and remanded. [Doc. 10.] Specifically, Plaintiff contends the ALJ erred by improperly evaluating the medical opinion of Larry Korn, M.D. [Id. at 18-25; Doc. 12.] The Commissioner, on the other hand, contends the ALJ's decision should be affirmed because the ALJ properly evaluated Dr. Korn's opinion. [Doc. 11 at 5-12.]
STANDARD OF REVIEW
The Commissioner's findings of fact are conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is more than a scintilla-i.e., the evidence must do more than merely create a suspicion of the existence of a fact and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966).
Where conflicting evidence “allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [Commissioner] (or the [Commissioner's] designate, the ALJ), ” not on the reviewing court. Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991) (stating that where the Commissioner's decision is supported by substantial evidence, the court will affirm, even if the reviewer would have reached a contrary result as finder of fact and even if the reviewer finds that the evidence preponderates against the Commissioner's decision). Thus, it is not within the province of a reviewing court to determine the weight of the evidence, nor is it the court's function to substitute its judgment for that of the Commissioner so long as the decision is supported by substantial evidence. See Bird v. Comm'r, 699 F.3d 337, 340 (4th Cir. 2012); Laws, 368 F.2d at 642; Snyder v. Ribicoff, 307 F.2d 518, 520 (4th Cir. 1962).
The reviewing court will reverse the Commissioner's decision on plenary review, however, if the decision applies incorrect law or fails to provide the court with sufficient reasoning to determine that the Commissioner properly applied the law. Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980); see also Keeton v. Dep't of Health & Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994). Where the Commissioner's decision “is in clear disregard of the overwhelming weight of the evidence, Congress has empowered the courts to modify or reverse the [Commissioner's] decision ‘with or without remanding the cause for a rehearing.'” Vitek v. Finch, 438 F.2d 1157, 1158 (4th Cir. 1971) (quoting 42 U.S.C. § 405(g)). Remand is unnecessary where “the record does not contain substantial evidence to support a decision denying coverage under the correct legal standard and when reopening the record for more evidence would serve no purpose.” Breeden v. Weinberger, 493 F.2d 1002, 1012 (4th Cir. 1974).
The court may remand a case to the Commissioner for a rehearing under sentence four or sentence six of 42 U.S.C. § 405(g). Sargent v. Sullivan, 941 F.2d 1207 (4th Cir. 1991) (unpublished table decision). To remand under sentence four, the reviewing court must find either that the Commissioner's decision is not supported by substantial evidence or that the Commissioner incorrectly applied the law relevant to the disability claim. See, e.g., Jackson v. Chater, 99 F.3d 1086, 1090-91 (11th Cir. 1996) (holding remand was appropriate where the ALJ failed to develop a full and fair record of the claimant's residual functional capacity); Brenem v. Harris, 621 F.2d 688, 690-91 (5th Cir. 1980) (holding remand was appropriate where record was insufficient to affirm but was also insufficient for court to find the claimant disabled). Where the court cannot discern the basis for the Commissioner's decision, a remand under sentence four is usually the proper course to allow the Commissioner to explain the basis for the decision or for additional investigation. See Radford v. Comm'r, 734 F.3d 288, 295 (4th Cir. 2013); see also Smith v. Heckler, 782 F.2d 1176, 1181-82 (4th Cir. 1986) (remanding case where decision of ALJ contained “a gap in its reasoning” because ALJ did not say he was discounting testimony or why); Gordon v. Schweiker, 725 F.2d 231, 235 (4th Cir. 1984) (remanding case where neither the ALJ nor the Appeals Council indicated the weight given to relevant evidence). On remand under sentence four, the ALJ should review the case on a complete record, including any new material evidence. See Smith, 782 F.2d at 1182 (“The [Commissioner] and the claimant may produce further evidence on remand.”). After a remand under sentence four, the court enters a final and immediately appealable judgment and then loses jurisdiction. Sargent, 941 F.2d 1207.
In contrast, sentence six provides:
The court may . . . at any time order additional evidence to be taken before the Commissioner of Social Security, but only upon a showing that there is new evidence which is material
and that there is good cause for the failure to incorporate such evidence into the record in a prior proceeding ....42 U.S.C. § 405(g). A reviewing court may remand a case to the Commissioner on the basis of new evidence only if four prerequisites are met: (1) the evidence is relevant to the determination of disability at the time the application was first filed; (2) the evidence is material to the extent that the Commissioner's decision might reasonably have been different had the new evidence been before him; (3) there is good cause for the claimant's failure to submit the evidence when the claim was before the Commissioner; and (4) the claimant made at least a general showing of the nature of the new evidence to the reviewing court. Borders v. Heckler, 777 F.2d 954, 955 (4th Cir. 1985) (citing 42 U.S.C. § 405(g); Mitchell v. Schweiker, 699 F.2d 185, 188 (4th Cir. 1983); Sims v. Harris, 631 F.2d 26, 28 (4th Cir. 1980); King v. Califano, 599 F.2d 597, 599 (4th Cir. 1979)), superseded by amendment to statute, 42 U.S.C. § 405(g), as recognized in Wilkins v. Sec'y, Dep't of Health & Human Servs., 925 F.2d 769, 774 (4th Cir. 1991). With remand under sentence six, the parties must return to the court after remand to file modified findings of fact. Melkonyan, 501 U.S. at 98. The reviewing court retains jurisdiction pending remand and does not enter a final judgment until after the completion of remand proceedings. See Allen v. Chater, 67 F.3d 293 (4th Cir. 1995) (unpublished table decision) (holding that an order remanding a claim for Social Security benefits pursuant to sentence six of 42 U.S.C. § 405(g) is not a final order).
Though the court in Wilkins indicated in a parenthetical that the four-part test set forth in Borders had been superseded by an amendment to 42 U.S.C. § 405(g), courts in the Fourth Circuit have continued to cite the requirements outlined in Borders when evaluating a claim for remand based on new evidence. See, e.g., Brooks v. Astrue, No. 6:10-cv-152, 2010 WL 5478648, at *8 (D.S.C. Nov. 23, 2010); Ashton v. Astrue, No. TMD 09-1107, 2010 WL 3199345, at *3 (D. Md. Aug. 12, 2010); Washington v. Comm'r of Soc. Sec., No. 2:08-cv-93, 2009 WL 86737, at *5 (E.D. Va. Jan. 13, 2009); Brock v. Sec'y of Health & Human Servs., 807 F.Supp. 1248, 1250 n.3 (S.D. W.Va. 1992). Further, the Supreme Court of the United States has not suggested Borders' construction of § 405(g) is incorrect. See Sullivan v. Finkelstein, 496 U.S. 617, 626 n.6 (1990). Accordingly, the Court will apply the more stringent Borders inquiry.
APPLICABLE LAW
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a disability. 42 U.S.C. § 423(a). “Disability” is defined as:
the inability 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 12 consecutive months.Id. § 423(d)(1)(A).
I. The Five-Step Evaluation
To facilitate uniform and efficient processing of disability claims, federal regulations have reduced the statutory definition of disability to a series of five sequential questions. See, e.g., Heckler v. Campbell, 461 U.S. 458, 461 n.2 (1983) (noting a “need for efficiency” in considering disability claims). The ALJ must consider whether (1) the claimant is engaged in substantial gainful activity; (2) the claimant has a severe impairment; (3) the impairment meets or equals an impairment included in the Administration's Official Listings of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1; (4) the impairment prevents the claimant from performing past relevant work; and (5) the impairment prevents the claimant from having substantial gainful employment. 20 C.F.R. §§ 404.1520, 416.920. Through the fourth step, the burden of production and proof is on the claimant. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). The claimant must prove disability on or before the last day of her insured status to receive disability benefits. Everett v. Sec'y of Health, Educ. & Welfare, 412 F.2d 842, 843 (4th Cir. 1969). If the inquiry reaches step five, the burden shifts to the Commissioner to produce evidence that other jobs exist in the national economy that the claimant can perform, considering the claimant's age, education, and work experience. Grant, 699 F.2d at 191. If at any step of the evaluation the ALJ can find an individual is disabled or not disabled, further inquiry is unnecessary. 20 C.F.R. §§ 404.1520(a), 416.920(a)(4); Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981).
A. Substantial Gainful Activity
“Substantial gainful activity” must be both substantial-involves doing significant physical or mental activities, 20 C.F.R. §§ 404.1572(a), 416.972(a)-and gainful-done for pay or profit, whether or not a profit is realized, Id. §§ 404.1572(b), 416.972(b). If an individual has earnings from employment or self-employment above a specific level set out in the regulations, he is generally presumed to be able to engage in substantial gainful activity. Id. §§ 404.1574-.1575, 416.974-.975.
B. Severe Impairment
An impairment is “severe” if it significantly limits an individual's ability to perform basic work activities. See id. §§ 404.1521, 416.921. When determining whether a claimant's physical and mental impairments are sufficiently severe, the ALJ must consider the combined effect of all of the claimant's impairments. 42 U.S.C. §§ 423(d)(2)(B), 1382c(a)(3)(G). The ALJ must evaluate a disability claimant as a whole person and not in the abstract, having several hypothetical and isolated illnesses. Walker v. Bowen, 889 F.2d 47, 49-50 (4th Cir. 1989) (stating that, when evaluating the effect of a number of impairments on a disability claimant, “the [Commissioner] must consider the combined effect of a claimant's impairments and not fragmentize them”). Accordingly, the ALJ must make specific and well-articulated findings as to the effect of a combination of impairments when determining whether an individual is disabled. Id. at 50 (“As a corollary to this rule, the ALJ must adequately explain his or her evaluation of the combined effects of the impairments.”). If the ALJ finds a combination of impairments to be severe, “the combined impact of the impairments shall be considered throughout the disability determination process.” 42 U.S.C. §§ 423(d)(2)(B), 1382c(a)(3)(G).
C. Meets or Equals an Impairment Listed in the Listings of Impairments
If a claimant's impairment or combination of impairments meets or medically equals the criteria of a listing found at 20 C.F.R. Pt. 404, Subpt. P, App.1 and meets the duration requirement found at 20 C.F.R. §§ 404.1509 or 416.909, the ALJ will find the claimant disabled without considering the claimant's age, education, and work experience. 20 C.F.R. §§ 404.1520(d), 416.920(a)(4)(iii), (d).
The Listing of Impairments is applicable to SSI claims pursuant to 20 C.F.R. §§ 416.911, 416.925.
D. Past Relevant Work
The assessment of a claimant's ability to perform past relevant work “reflect[s] the statute's focus on the functional capacity retained by the claimant.” Pass v. Chater, 65 F.3d 1200, 1204 (4th Cir. 1995). At this step of the evaluation, the ALJ compares the claimant's residual functional capacity with the physical and mental demands of the kind of work he has done in the past to determine whether the claimant has the residual functional capacity to do his past work. 20 C.F.R. §§ 404.1560(b), 416.960(b).
Residual functional capacity is “the most [a claimant] can still do despite [his] limitations.” 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1).
E. Other Work
As previously stated, once the ALJ finds that a claimant cannot return to her prior work, the burden of proof shifts to the Commissioner to establish that the claimant could perform other work that exists in the national economy. See 20 C.F.R. §§ 404.1520(f)-(g), 416.920(f)-(g); Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992). To meet this burden, the Commissioner may sometimes rely exclusively on the Medical-Vocational Guidelines (the “grids”). Exclusive reliance on the “grids” is appropriate where the claimant suffers primarily from an exertional impairment, without significant nonexertional factors. 20 C.F.R. Pt. 404, Subpt. P, App. 2, § 200.00(e); Gory v. Schweiker, 712 F.2d 929, 930-31 (4th Cir. 1983) (stating that exclusive reliance on the grids is appropriate in cases involving exertional limitations). When a claimant suffers from both exertional and nonexertional limitations, the grids may serve only as guidelines. Gory, 712 F.2d at 931. In such a case, the Commissioner must use a vocational expert to establish the claimant's ability to perform other work. 20 C.F.R. §§ 404.1569a, 416.969a; see Walker, 889 F.2d at 49-50 (“Because we have found that the grids cannot be relied upon to show conclusively that claimant is not disabled, when the case is remanded it will be incumbent upon the [Commissioner] to prove by expert vocational testimony that despite the combination of exertional and nonexertional impairments, the claimant retains the ability to perform specific jobs which exist in the national economy.”). The purpose of using a vocational expert is “to assist the ALJ in determining whether there is work available in the national economy which this particular claimant can perform.” Walker, 889 F.2d at 50. For the vocational expert's testimony to be relevant, “it must be based upon a consideration of all other evidence in the record, . . . and it must be in response to proper hypothetical questions which fairly set out all of claimant's impairments.” Id. (citations omitted).
An exertional limitation is one that affects the claimant's ability to meet the strength requirements of jobs. 20 C.F.R. §§ 404.1569a(a), 416.969a(a). A nonexertional limitation is one that affects the ability to meet the demands of the job other than the strength demands. Id. Examples of nonexertional limitations include but are not limited to difficulty functioning because of being nervous, anxious, or depressed; difficulty maintaining attention or concentrating; difficulty understanding or remembering detailed instructions; difficulty seeing or hearing. 20 C.F.R. §§ 404.1569a(c)(1), 416.969a(c)(1).
II. Developing the Record
The ALJ has a duty to fully and fairly develop the record. See Cook v. Heckler, 783 F.2d 1168, 1173 (4th Cir. 1986). The ALJ is required to inquire fully into each relevant issue. Snyder, 307 F.2d at 520. The performance of this duty is particularly important when a claimant appears without counsel. Marsh v. Harris, 632 F.2d 296, 299 (4th Cir. 1980). In such circumstances, “the ALJ should scrupulously and conscientiously probe into, inquire of, and explore for all the relevant facts, . . . being especially diligent in ensuring that favorable as well as unfavorable facts and circumstances are elicited.” Id. (internal quotations and citations omitted).
III. Medical Opinions
For claims filed on or after March 27, 2017, as Plaintiff's are, the applicable regulations require ALJs to consider the persuasiveness of each medical opinion of record in accordance with the following factors: (1) supportability; (2) consistency; (3) relationship with the claimant; (4) specialization; and (5) other factors that tend to support or contradict the opinion. 20 C.F.R. §§ 404.1520c(b), (c), 416.920c(b), (c). Regarding supportability, “[t]he more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion . . . the more persuasive the medical opinion will be.” 20 C.F.R. §§ 404.1520c(c)(1), 416.920c(c)(1). As for the relationship with the claimant, ALJs consider the “length of the treatment relationship, ” the “[f]requency of examinations, ” the “[p]urpose of the treatment relationship, ” the “[e]xtent of the treatment relationship, ” and whether the source has examined the claimant. 20 C.F.R. §§ 404.1520c(c)(3), 416.920c(c)(3).
The new regulations define the term “medical opinion” as “a statement from a medical source about what you can still do despite your impairment(s) and whether you have one or more impairment-related limitations or restrictions.” 20 C.F.R. §§ 404.1513(a)(2), 416.913(a)(2).
IV. Medical Tests and Examinations
The ALJ is required to order additional medical tests and exams only when a claimant's medical sources do not give sufficient medical evidence about an impairment to determine whether the claimant is disabled. 20 C.F.R. §§ 404.1517, 416.917; see also Conley v. Bowen, 781 F.2d 143, 146 (8th Cir. 1986). The regulations are clear: a consultative examination is not required when there is sufficient medical evidence to make a determination on a claimant's disability. 20 C.F.R. §§ 404.1517, 416.917. Under the regulations, however, the ALJ may determine that a consultative examination or other medical tests are necessary. Id.
V. Pain
Congress has determined that a claimant will not be considered disabled unless he furnishes medical and other evidence (e.g., medical signs and laboratory findings) showing the existence of a medical impairment that could reasonably be expected to produce the pain or symptoms alleged. 42 U.S.C. § 423(d)(5)(A). Social Security Ruling (“SSR”) 16-3p provides, “[i]n considering the intensity, persistence, and limiting effects of an individual's symptoms, we examine the entire case record, including the objective medical evidence; an individual's statements about the intensity, persistence, and limiting effects of symptoms; statements and other information provided by medical sources and other persons; and any other relevant evidence in the individual's case record.” Social Security Ruling 16-3p Titles II and XVI: Evaluation of Symptoms In Disability Claims, 82 Fed.Reg. 49, 462, 49, 464 (Oct. 25, 2017); see also 20 C.F.R. §§ 404.1529(c)(1)-(2), 416.929(c)(1)-(2) (outlining evaluation of pain).
In evaluating claims of disabling pain, the ALJ must proceed in a two-part analysis. Morgan v. Barnhart, 142 Fed.Appx. 716, 723 (4th Cir. 2005) (unpublished opinion); see also SSR 16-3p, 82 Fed.Reg. at 49, 463. First, “the ALJ must determine whether the claimant has produced medical evidence of a ‘medically determinable impairment which could reasonably be expected to produce” the alleged symptoms. Id. (quoting Craig, 76 F.3d at 594); see SSR 16-3p, 82 Fed.Reg. at 49, 463. Second, the ALJ must evaluate “the intensity and persistence of an individual's symptoms such as pain and determine the extent to which an individual's symptoms limit his or her ability to perform work-related activities . . . or to function independently.” SSR 16-3p, 82 Fed.Reg. at 49, 464; see 20 C.F.R. §§ 404.1528, 416.928 (noting that the ALJ must consider all of a claimant's statements about his symptoms, including pain, and determine the extent to which the symptoms can reasonably be accepted as consistent with the objective medical evidence).
APPLICATION AND ANALYSIS
As noted, Plaintiff argues that the ALJ erred in discrediting Dr. Korn's opinions. [Docs. 10 at 18-25; 12.]. The Court disagrees.
The ALJ's Analysis
The ALJ analyzed Plaintiff's claim as follows:
The claimant testified that she stopped working due to back pain. She alleges symptoms and limitations secondary to a history of heart attacks with stent placement and diabetes. She has numbness and pain in her hands and feet. Her feet and knees are painful and swell. She has fatigue difficulties balancing, gripping and picking up small items. The claimant also alleged medication side effects that include drowsiness.
After careful consideration of the evidence, I find that the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.
At the hearing, claimant alleged symptoms attributable to fibromyalgia. However, the medical record contains no evidence showing that the claimant exhibits the symptoms associated with this impairment. Specifically, the record does not confirm that the claimant has the requisite number of tender point findings. The lack of specificity fails to satisfy the criteria necessary to find fibromyalgia a severe impairment. Moreover, there is no evidence that medical doctors have excluded other impairments as required by SSR 12-2p. X-rays of the hips revealed very mild degenerative changes in the left hip. X-rays of the left knee were normal (Exhibit 5F). As discussed below, there is evidence of degenerative disc disease and possible neuropathy, both of which may be an etiology for the claimant's alleged symptoms. Thus, this
diagnosis does not comport with the requirements set forth in either SSR 12-2p or 96-4p that requires that an “impairment” must result from anatomical, physiological or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. Consequently, I find that this impairment does not meet the requirements set forth by the Social Security Administration needed for the determination that fibromyalgia is a medically determinable impairment.
In terms of claimant's symptoms related to coronary artery disease, degenerative disc disease, and diabetes with neuropathy, I have limited the claimant to less than a full range of light work. In limiting the claimant to light work, I have also accounted for the compounding effects the claimant's obese habitus has on her other impairments. For instance, her weight may further complicate her lower back pain and fatigue. However, the objective findings do not support further restrictions to the claimant's RFC.
In limiting the claimant's RFC, I find the opinions of the State agency medical consultants to be persuasive. The State agency medical consultants found the claimant to have light exertional limitations with occasionally lifting/carrying up to 20 pounds, frequently carrying/lifting up to 10 pounds, sitting up to 6 hours in an 8-hour workday, and standing/walking at least 6 hours in an 8-hour workday. The consultant found the claimant limited to have occasional postural limitations with the exception of climbing ladders/ropes/scaffolds, which they limited to never. They also noted limitations from exposure to hazards (Exhibits 1A and 5A). Although they are non-treating and non-examining medical sources, they are familiar with Agency rules and regulations and they were able to review the claimant's medical history. Furthermore, their opinions are consistent with the weight of the objective medical evidence, discussed below.
While the record notes diagnoses and treatments for degenerative disc disease, coronary artery disease, diabetes and obesity, the longitudinal objective medical findings are not consistent with the claimant's allegations of disabling physical limitations.
Regarding the claimant's coronary artery disease, evidence documents a June 19, 2017 hospital admission for complaints
of chest tightness and pressure secondary to an ST-elevation myocardial infarction. The claimant was assessed with acute coronary artery syndrome and diabetes mellitus. She was noted to have moderate left ventricular dysfunction. She underwent a percutaneous coronary intervention and was transferred to the CCU for 48-hour observation. She denied further symptoms of angina and remained hemodynamically stable. Her ejection fraction was estimated to be 40 to 45 percent and she was deemed ready for discharge (Exhibit 1F).
Subsequent records note improvement and stability in symptoms. For instance, follow-up cardiology records through December of 2017 note that the claimant is doing well with her coronary artery disease symptoms and she has had no significant interval events. She denied chest pain at rest and exertional chest pain was stable. She denied dyspnea and fatigue and her exercise tolerance had improved (Exhibit 2F).
On June 18, 2018, the claimant reported symptoms of mild shortness of breath. A stress test was abnormal showing and consistent with ischemic cardiomyopathy. Left ventricular systolic function was abnormal with small defect noted. An echocardiogram revealed evidence of mild cardiomyopathy and mild mitral regurgitation (Exhibit 8F). On July 25, 2018, the claimant continued to report shortness of breath on exertion and fatigue. However, no ischemia was noted on stress test and no acute EKG changes were noted (Exhibit 10F).
The claimant was admitted to the hospital on November 5, 2018 with symptoms of dizziness and pain in the left arm and jaw. A left heart catheterization revealed patent stents and an EKG was normal. The claimant's pain resolved and she was transferred to telemetry floor for observation. While there, she remained hemodynamically stable and she was deemed stable for discharge (Exhibit 13F). Follow-up primary care records note that the claimant feels well (Exhibit 14F). Cardiology records from December of 2018 note that the claimant has been doing well since her last visit. Her dyspnea and fatigue are stable (Exhibit 15F). On June 20, 2019, the claimant reported ongoing shortness of breath symptoms with exertion. Her fatigue showed mild improvement with medication and she denied chest pain (Exhibit 21F).
Regarding the claimant's alleged back pain, diagnostic x-rays of the lumbar spine dated May 11, 2018 revealed evidence of scoliosis and spondylosis with marked disc space narrowing at ¶ 5-S1 (Exhibit 5F). However, longitudinal objective examination findings do not warrant the imposition of additional restrictions of the claimant's RFC.
Primary care records from January 31, 2017, note that the claimant feels well and exercises several times a week (Exhibit 3F). Hospital records dated June 19, 2017 note that the claimant exhibited normal ranges of motion (Exhibit 1F).
On November 29, 2017, the claimant reported having more problems with neuropathy during the day; however, she stated that she feels well. The claimant denied joint or back pain and no edema was appreciated in the lower extremities (Exhibit 3F). Primary care records from May of 2018 note that the claimant feels well and she denied joint pain, back pain, joint swelling, weakness, numbness or fatigue (Exhibit 7F).
On October 4, 2018, treatment notes document complaints of lower back pain (Exhibit 12F). However, hospital records dated November 5, 2018 note that the claimant exhibited good ranges of motion in the extremities without pain. Neurovascular and tendon function were intact with no evidence of edema or tenderness. No motor or sensory deficits were appreciated. The claimant exhibited adequate range of motion in the back with no pain on movement (Exhibit 13F). Primary care records from February of 2019 note that the claimant's type II diabetes remains uncontrolled; however, she feels well (Exhibit 17F). On April 1, 2019, the claimant reported muscle pain; however, an examination of the affected muscles did not reveal any abnormalities (Exhibit 19F).
In sum, the longitudinal treatment record supports limiting the claimant to light work with additional postural and environmental restrictions. Overall, the objective examinations are not consistent with the claimant's allegations of disabling functional limitations. Rather, they support the RFC findings of the State agency medical consultants.
I find the opinion of the State agency consultative examiner to be less persuasive as it is inconsistent with the weight of the objective medical record. In addition, Dr. Korn is a one-time examining source who lacks a longitudinal treatment history
with the claimant. On May 11, 2018, Dr. Korn assessed the claimant with likely significant lumbosacral spondylosis with left lower extremity radiculopathy, very severe upper body/central obesity complicating her lower back issues, and mild/early diabetic peripheral neuropathy. On exam, he noted that the claimant had poor muscle tone. Ranges of motion were limited in the cervical and lumbar spine. However, straight leg raising was negative bilaterally. An exam of the knees was unremarkable. The hands appeared normal and her ability to do fine and gross manipulations was a little below average due to deficits in strength and slightly diminished dexterity. She was limited in tandem, heel-toe walking and squatting. However, her gait was fairly normal. No sensory loss was appreciated. Dr. Korn concluded that the claimant is not capable of any heavy general labor activities even for the briefest of durations. While this conclusion is not inconsistent with the RFC limitations noted above, Dr. korn further noted that the claimant is not very strong and does not have a lot of good physical attributes. There is significant dysmorphia in her body due to her obesity and chronic disease. He concluded that the claimant would require markedly light duties that she can move from seated to standing position as her discomfort dictates. He further concluded that she is going to be a little below average in her ability to do rapid fine precise manipulations versus the competition. Her balance is “not terribly good” due to loss of strength more than neuropathy, thus she should not work above floor level or in close proximity to dangerous moving machinery (Exhibit 6F). However, his findings are inconsistent with the longitudinal objective medical findings. For instance, hospital records dated November 5, 2018 note that the claimant exhibited good ranges of motion in the extremities without pain. Neurovascular and tendon function were intact with no evidence of edema or tenderness. No motor or sensory deficits were appreciated. The claimant exhibited adequate range of motion in the back with no pain on movement (Exhibit 13F). Primary care records from February of 2019 note that the claimant feels well (Exhibit 17F). On April 1, 2019, an examination of the affected muscles did not reveal any abnormalities (Exhibit 19F).
[R. 22-25.]
Discussion
Plaintiff contends that the ALJ's statement that Dr. Korn's opinions were inconsistent with the “weight of the objective medical record” was not sufficiently specific to support his decision to discredit Dr. Korn's opinions. [Doc. 10 at 22.] Regarding the ALJ's observation that Dr. Korn was “a one-time examining source who lacks a longitudinal treatment history with the claimant, ” Plaintiff notes that “there was no provider who gave an opinion contradicting Dr. Korn's opinion with a greater treatment relationship than Dr. Korn had.” [Id. at 23.] To the extent the ALJ pointed to objective findings seemingly at odds with Dr. Korn's examination findings, Plaintiff argues that those findings do “not automatically disprove Dr. Korn's specific examination findings, ” and Plaintiff maintains that the record evidence “clearly shows that [Plaintiff] had continued pain and conditions capable of producing her pain symptoms and supporting the limitations given by Dr. Korn.” [Id.] Plaintiff argues that the ALJ simply cherry-picked the evidence that tended to indicate that Plaintiff's symptoms were not serious, including isolated references to Plaintiff “feeling well, ” and the like. [Id. at 24-25.] However, the Court concludes that substantial evidence supported the ALJ's evaluation of Dr. Korn's opinions.
Most of Plaintiff's arguments essentially claim that the ALJ did not fairly or persuasively explain why he found Dr. Korn's opinions to be inconsistent with the longitudinal objective medical findings. The Court simply disagrees with those arguments. The ALJ appeared to focus on Dr. Korn's statement that Plaintiff “would require markedly light duties that she can move from seated to standing position as her discomfort dictates.” [R. 25.] Although Dr. Korn believed that such a restriction was justified given Plaintiff's description of constant pain in her lumbosacral junction and sharp shooting pains down her left leg generally every day that require her to get up and move around after sitting for 15 minutes, the ALJ noted that Plaintiff's medical records often reflected that Plaintiff reported feeling well or having good range of motion in the extremities without pain, or similar facts. [R. 25.] Plaintiff accuses the ALJ of cherry-picking positive evidence, but that is not the Court's view of the record. In fact, other than one medical visit when Plaintiff complained that her toes and feet were painful [R. 546], Plaintiff does not point to any evidence that in the four years prior to Dr. Korn's examination, she complained to a medical provider of lower back pain or any other sort of pain that would prevent her from sitting for more than a few minutes without getting up and moving around. See 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2) (providing that “[t]he more consistent a medical opinion(s) . . . is with the evidence from other medical sources and nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior administrative medical finding(s) will be”). Especially given that Dr. Korn saw Plaintiff on only one occasion and had no prior treatment relationship with her, the ALJ was on firm ground in finding Dr. Korn's opinions unpersuasive. See 20 C.F.R. §§ 404.1520c(c)(3), 416.920c(c)(3) (providing that, regarding a medical source's relationship with the claimant, ALJs consider the “length of the treatment relationship, ” the “[f]requency of examinations, ” the “[p]urpose of the treatment relationship, ” the “[e]xtent of the treatment relationship, ” and whether the source has examined the claimant). Accordingly, the Court concludes that substantial evidence supports the ALJ's decision and recommends that the decision be affirmed. See Edwards v. Saul, No. 1:20-cv-2280-SVH, 2021 WL 210852, at *13 (D.S.C. Jan. 20, 2021) (holding that the ALJ's rejection of limitations included in a medical opinion was supported by substantial evidence when the ALJ considered the absence of a treatment relationship, noted that the doctor appeared to rely on Plaintiff's subjective presentation, and cited evidence that appeared to conflict with the doctor's observations).
Plaintiff points to a record noting that she had pain when bending and twisting. [Doc. 10 at 25 (citing R. 760).] The Court notes, however, that the record appears to be from April 2019, several years after Plaintiff's date last insured.
To the extent that Plaintiff argues that the ALJ erred in crediting medical opinions of medical consultants who did not examine Plaintiff when the ALJ discredited Dr. Korn's opinion, Plaintiff fails to take into account that the ALJ found the opinions of these other consultants to be consistent with the weight of the objective medical evidence. See 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2).
CONCLUSION AND RECOMMENDATION
Wherefore, based upon the foregoing, the Court recommends that the Commissioner's decision be AFFIRMED.
IT IS SO RECOMMENDED.