Opinion
Case No. 05cv1682 WQH (PCL).
April 11, 2006
REPORT AND RECOMMENDATION DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT; GRANTING DEFENDANT'S CROSS-MOTION FOR SUMMARY JUDGMENT
INTRODUCTION
On August 26, 2005, Plaintiff filed this action pursuant to § 405(g) of the Social Security Act ("Act"), 42 U.S.C. § 1383(c), to obtain judicial review of a final decision of the Commissioner of the Social Security Administration ("Commissioner") denying his claim for Disability Insurance Benefits under Title II of the Act. The Honorable Thomas J. Whelan referred the matter to this Court of Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). The parties filed cross-motions for summary judgment which were taken under submission without oral argument. After a thorough review of the pleadings filed by the parties and the entire record submitted in this matter, and for the reasons set forth below, this Court recommends that Plaintiff's motion for summary judgment by DENIED, and Defendant's cross-motion for summary judgment be GRANTED.
BACKGROUND
1. Procedural BackgroundOn March 19, 2004, Plaintiff filed an application for Disability Insurance Benefits, which was initially denied. On February 25, 2005, the administrative law judge ("ALJ") denied benefits on reconsideration and after a review hearing held on January 5, 2005. The decision of the Social Security Administration became final when the Appeals Council denied Plaintiff's request for review on June 27, 2005. The instant Complaint was timely filed on August 26, 2005. Defendant filed an Answer to the Complaint on October 19, 2005. Plaintiff filed a motion for summary judgment ("Mot."), ambiguously entitled Plaintiff's Motion for Reversal and/or Remand, on December 19, 2005. Defendant filed an opposition and a cross-motion for summary judgment ("Opp'n") on January 3, 2006.
2. Factual Background
Plaintiff was born on August 14, 1943. Transcript ("Tr.") at 47. He has a second grade education and is able to read, write and speak English. Tr. at 55, 59. His former occupations include employment as a security guard from 1997 to 2002. Tr. at 56. Plaintiff claims that he became disabled on October 7, 2002 due to high blood pressure and an intracranial injury. Tr. at 47. Plaintiff's date last insured was March 31, 2003. Tr. at 54.
3. Medical Background
On September 3, 2002, Plaintiff arrived at the Sharp Emergency Room in a hypertensive crisis, consisting of a severe headache, diaphoresis, nausea and vomiting. Tr. at 81-84. An emergency head CT revealed a diffuse subarachnoid hemorrhage. Tr. at 84. Plaintiff was transferred to Scripps Memorial Hospital in La Jolla where an angiogram revealed a right posterior communicating artery aneurysm. Plaintiff was taken into surgery by Dr. Vrijesh S. Tantuwaya, M.D. the same day and the aneurysm was completely clipped. Dr. Tantuwaya noted that the procedure went very well with no complications. Id. The postoperative course was uneventful and Plaintiff made an excellent recovery. Plaintiff was discharged home approximately one week later with Dilantin for seizure prophylaxis and Tylenol #3 for headaches. On a follow-up visit September 27, 2002, Dr. Tantuwaya reported that Plaintiff had made an excellent recovery and noted no complaints. The doctor continued Plaintiff on Dilantin for approximately 3 more months. Id.
Diaphoresis is a synonym for perspiration. Stedman's Medical Dictionary 493 (27th ed. 2000).
Plaintiff was then treated by Dr. Trung Quy Tran, M.D. from October 1, 2002 to April 26, 2004. Tr. at 88-89. Dr. Tran treated Plaintiff for hypertension. Tr. at 85. Dr. Tran also treated Plaintiff for a complaint of back pain made on July 2, 2003. Tr. at 95.
The Court notes that the records reflecting treatment by Dr. Tran are for the most part illegible. The Court hesitates to interpret them. Instead, the Court will use Plaintiff's and Defendant's non-conflicting statements in the instant motions to aid the Court. Accordingly, the Court will find the reports to reflect Dr. Tran assessed Plaintiff with hypertension on October 1, 2002, and assessed Plaintiff with back pain on July 2, 2003. (Mot. at 5; Opp'n at 3).
On October 6, 2002, Plaintiff arrived at the Scripps Memorial Hospital Emergency Room with complaints of right upper quadrant pain and right flank pain. Tr. at 100. Dr. David J. Smith, M.D. found an infiltrate at Plaintiff's lung base with some pleural reaction. Dr. Smith treated Plaintiff for pneumonia with pleuritic chest pain and mild hypoxia. Tr. at 102. Plaintiff was discharged the following day. Tr. at 103.
Pleural relates to the serous membrane enveloping the lungs and lining the walls of the pleural cavity. Stedman's at 1399.
Hypoxia is a decrease below normal levels of oxygen in inspired gases, arterial blood, or tissue, just short of a complete absence. Stedman's at 867.
On March 19, 2004, Plaintiff filed for Disability Benefits. At the direction of the Department of Social Services, Plaintiff had an internal medicine evaluation conducted by Dr. Steven E. Gerson, D.O. Tr. at 104. Plaintiff's chief complaints were of hypertension and joint pain. Id. Dr. Gerson found that Plaintiff's blood pressure was 138/80. Tr. at 107. His heart, lung, and abdominal exams were within normal limits. Id. Neurologically, he was nonfocal and intact for motor, sensory, reflexes, and cerebellar. His grip strength was firm and symmetric. His fine motor coordination was intact with no nystagmus or tremor. Plaintiff's gait was slow with a mild limp but there was no ataxia or instability. Plaintiff had bilateral knee joint tenderness but had full range of motion with no edema, crepitus, or joint instability. Id. Plaintiff's back exam showed midline thoracic and lumbar spinal tenderness and paralumbar muscle tenderness with decreased range of motion. Id. The decreased range of motion consisted of only a five degree forward flexion loss while the retroflexion and lateral flexion was normal. Tr. at 106, 121. Also, the straight leg raise test was negative and the exam was not consistent with an acute lumbar radiculopathy. Tr. at 107. Plaintiff also had left dorsal ankle tenderness but had a full range of motion with no effusion, warmth, or synovitis. Tr. at 108. Dr. Gerson noted that Plaintiff did not appear acutely toxic or fatigued. Dr. Gerson found that Plaintiff should be able to lift 25 pounds frequently and 50 pounds occasionally. Plaintiff could also stand and walk for 6 hours in an 8 hour workday and sit for 6 hours in an 8 hour workday. Id.
Nystagmus is the involuntary rhythmic to-and-fro movement of the eyeballs, either pendular or with a slow and fast component. Stedman's at 1246.
Ataxia is the inability to coordinate muscle activity during voluntary movement; most often due to disorders of the cerebellum or the posterior columns of the spinal cord.Stedman's at 161.
Edema is an accumulation of an excessive amount of watery fluid in cells or intercellular tissues. Stedman's at 566.
Crepitus is the grating of a joint, often in association with osteoarthritis. Stedman's at 424.
Radiculopathy is a disorder of the spinal nerve roots.Stedman's at 1503.
Effusion is the escape of fluid from the blood vessels or lymphatics into the tissues or a cavity. Stedman's at 570.
Synovitis is the inflammation of a synovial membrane, especially that of a joint; in general, when unqualified, the same as arthritis. Stedman's at 1773.
On June 2, 2004, Dr. Albert Lizarraras, M.D. reviewed Dr. Gerson's findings and concurred that the evidence supports medium exertion level due to knee pain. Tr. at 117. The findings were again reviewed on July 13, 2004 by Dr. G. Taylor-Holmes, M.D. who also concurred. Tr. at 120-121.
3. The ALJ's Decision
The ALJ, in a written opinion, found that based on the application filed on March 19, 2004, "the claimant is not entitled to a period of disability or Disability Insurance Benefits under Sections 216(I) and 223, respectively, of the Social Security Act." (Tr. at 18) The ALJ's decision was based on the following findings:
1. The claimant meets the nondisability requirements for a period of disability and Disability Insurance Benefits set forth in Section 216(I) of the Social Security Act and is insured for benefits through March 31, 2003.
2. The claimant has not engaged in substantial gainful activity since the alleged onset of disability.
3. The claimant has the following medically determinable impairment(s): high blood pressure and intracranial injury. The claimant is status post subarachnoid hemorrhage (SAH) and a craniotomy for a right passive cutaneous anaphylaxis (PCA) aneurysm with excellent results.
4. The claimant does not have any impairment or impairments that significantly limit his ability to perform basic work-related activities; therefore, the claimant does not have a "severe" impairment ( 20 C.F.R. § 404.1520).
5. The claimant was not under a "disability" as defined in the Social Security Act, at any time through the date of this decision ( 20 C.F.R. § 404.1520(c)).
Tr. at 17.
LEGAL STANDARD
1. Scope of Review
Section 405(g) of the Act allows unsuccessful applicants to seek judicial review of a final agency decision of the Commissioner. 42 U.S.C. § 405(g). The scope of judicial review is limited. The Commissioner's denial of benefits "will be disturbed only if it is not supported by substantial evidence or is based on legal error." Brawner v. Secretary of Health and Human Servs., 839 F.2d 432, 433 (9th Cir. 1988) (citing Green v. Heckler, 803 F.2d 528, 529 (9th Cir. 1986)).
Substantial evidence means "more than a mere scintilla" but less than a preponderance. Sandgathe v. Chater, 108 F.3d 978, 980 (9th Cir. 1997) (citation omitted). "[I]t is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (quoting Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995)). The court must consider the record as a whole, weighing both the evidence that supports and detracts from the Commissioner's conclusions. Desrosiers v. Secretary of Health Human Servs., 846 F.2d 573, 576 (9th Cir. 1988) (citingJones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985)). If the evidence supports more than one rational interpretation, the court must uphold the ALJ's decision. Allen v. Heckler, 749 F.2d 577, 579 (9th Cir. 1984). When the evidence is inconclusive, "questions of credibility and resolution of conflicts in the testimony are functions solely of the Secretary." Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982).
Even if the reviewing court finds that substantial evidence supports the ALJ's conclusions, the court must set aside the decision if the ALJ failed to apply the proper legal standards in weighing the evidence and researching a decision. See Benitez v. Califano, 573 F.2d 653, 655 (9th Cir. 1978). Section 405(g) permits a court to enter a judgment affirming, modifying, or reversing the Commissioner's decision. 42 U.S.C. § 405(g). The reviewing court may also remand the matter to the Social Security Administrator for further proceedings. Id.
2. Qualifying for Disability Benefits
To qualify for disability benefits under the Social Security Act, an applicant must show that: (1) he or she suffers from a medically determinable impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of twelve months or more; and (2) the impairment renders the applicant incapable of performing the work that he or she previously performed or any other substantially gainful employment that exists in the national economy. See 42 U.S.C. § 423(d)(1)(A), (2)(A). An applicant must meet both requirements to be "disabled." Id.
The Secretary of the Social Administration has established a five-step sequential evaluation process for determining whether a person is disabled. 20 C.F.R. §§ 404.1520, 416.920. Step one determines whether the claimant is engaged in "substantial gainful activity." If he is, disability benefits are denied. 20 C.F.R. §§ 404.1520(b), 416.920(b). If he is not, the decision maker proceeds to step two, which determines whether the claimant has a medically severe impairment or combination of impairments.
The determination of whether an impairment or combination of impairments is severe is governed by the "severity regulation" at issue in this case. The severity regulation provides in relevant part: "If you do not have any impairment or combination of impairments which significantly limits your physical or mental ability to do basic work activities, we will find that you do not have a severe impairment and are, therefore, not disabled. We will not consider your age, education, and work experience." 20 C.F.R. §§ 404.1520(c), 416.920(c). The ability to do basic work activities is defined as "the abilities and aptitudes necessary to do most jobs." 20 C.F.R. §§ 404.1521(b), 416.921(b). Such abilities and aptitudes include physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling, as well as the capacity for seeing, hearing, and speaking understanding, carrying out, and remembering simple instructions, use of judgment, responding appropriately to supervision, co-workers, and usual work situations, and dealing with changes in a routine work setting.Id. A significant work-related limitation of function involves something more than minimal or slight but less than severe.Fanning v. Bowen, 827 F. 2d 631, 633 (9th Cir. 1986) The severity regulation is satisfied when a claimant is limited to light or sedentary work. Id. If the claimant does not have a severe impairment or combination of impairments, or in cases where there is no more than a minimal effect on the claimant's ability to work, the disability claim is denied. See Bowen v. Yuckert, 482 U.S. 137, 153 (1987). The burden of proof at step two is on the claimant. Bowen v. Yuckert, 482 U.S. 137, 146 fn. 5 (1987).
If the impairment is severe, the evaluation proceeds to the third step, which determines whether the impairment is equivalent to one of a number of listed impairments that the Secretary acknowledges are so severe as to preclude substantial gainful activity. 20 C.F.R. §§ 404.1520(d), 416.920(d); 20 C.F.R. Part 404, Appendix 1 to Subpart P. If the impairment meets or equals one of the listed impairments, the claimant is conclusively presumed to be disabled. If the impairment is not one that is conclusively presumed to be disabling, the evaluation proceeds to the fourth step, which determines whether the impairment prevents the claimant from performing work he has performed in the past. If the claimant is able to perform his previous work, he is not disabled. 20 C.F.R. §§ 404.1520(e), 416.920(e). If the claimant cannot perform his previous work, the fifth and final step of the process determines whether he is able to perform other work in the national economy in view of his age, education, and work experience. The claimant is entitled to disability benefits only if he is not able to perform other work. 20 C.F.R. §§ 404.1520(f), 416.920(f).
ANALYSIS
Plaintiff moves for summary judgment on the grounds that the ALJ's decision was not supported by substantial evidence. Specifically, Plaintiff contends that the ALJ erred at step two in finding Plaintiff's medical impairments were not severe when there was no medical evidence presented to the contrary. (Mot. at 8) Defendant argues that the ALJ's decision was not in error and was supported by substantial evidence. (Opp'n at 5)
In this case, the ALJ found Plaintiff to have two medically determinable impairments, high blood pressure and an intracranial injury. The ALJ further found that those impairments were not severe to significantly limit Plaintiff's ability to perform basic work-related activities. The ALJ also found Plaintiff's allegations of debilitating pain and disabling functional limitation not fully credible. This Court's review of the record reveals that the ALJ based his opinion on substantial evidence.
1. Intracranial Injury
The record reveals Dr. Tantuwaya performed surgery on Plaintiff to clip the right posterior communicating artery aneurysm. Dr. Tantuwaya noted that the procedure went very well with no complications. Dr. Tantuwaya further noted that the postoperative course was uneventful and Plaintiff made an excellent recovery. On a follow up visit three weeks later, Dr. Tantuwaya reported that Plaintiff had made an excellent recovery with no complaints. Almost two years later, Dr. Gerson reported that neurologically, Plaintiff was nonfocal and intact for motor, sensory, reflexes, and cerebellar. Dr. Gerson also found that Plaintiff's fine motor coordination was intact with no nystagmus or tremors. Dr. Gerson reported that Plaintiff's gait was slow with a mild limp but there was no ataxia or instability. Finally, Dr. Lizarraras reported that no functionally significant neurological deficits have been described. Tr. at 117.
According to the medical evidence, there is no documentation that relates to any problems or complaints from the aneurysm or surgery. Thus, this Court finds that the ALJ's decision that Plaintiff suffered no severe impairments due to the intracranial injury that would limit his ability to perform basic work functions is supported by substantial evidence.
2. Hypertension
The record reveals Plaintiff was diagnosed with hypertension by both Dr. Gerson and Dr. Lizarraras. However, Dr. Lizarraras reported that Plaintiff's hypertension had been well controlled with no evidence of end organ damage. Tr. at 117. Dr. Gerson reported that Plaintiff's blood pressure at the time of the exam was 138/80, which is a good range. Finally, Dr. Tran monitored Plaintiff's blood pressure for two years with no noted problems.
The record is void of any negative effects upon Plaintiff from hypertension. Thus, this Court finds that there is substantial evidence that Plaintiff suffered no severe impairments due to his hypertension that would limit his ability to perform basic work functions.
3. Back, Joint, and Knee Pain
The ALJ considered and rejected Plaintiff's complaints of back, joint, and knee pain. The ALJ may not discredit Plaintiff's claims of pain merely because they are unsupported by objective medical findings. Bunnel v. Sullivan, 947 F.2d 341, 345 (9th Cir. 1991). Instead, the ALJ must justify the decision to reject such claims as not credible with specific findings that are supported by substantial evidence in the record. Id. At 354-46;Fair v. Bowen, 885 F.2d 597, 602 (9th Cir. 1989). Any such finding must be "sufficiently specific to permit the reviewing court to conclude that the ALJ did not arbitrarily discredit the claimant's testimony." Orteza v. Shalala, 50 F.3d 748, 750 (9th Cir. 1994).
First, a review of the record shows that the ALJ's decision is supported by substantial evidence. Plaintiff reported to Dr. Gerson that he had been suffering from back and joint pain for two years. Tr. at 104. Plaintiff stated that his pain is constant and worse with bending, sitting, standing, and walking, but is relieved with rest and Tylenol. However, his treatment records only document one complaint of back pain on July 2, 2003. Plaintiff did not recall having an x-ray or MRI and has not had physical therapy or seen an orthopedic surgeon. According to Dr. Gerson's report, Plaintiff stated that he had no leg numbness, and the pain did not change with coughing or sneezing. Id. Dr. Gerson's examination of Plaintiff revealed midline thoracic and lumbar spinal tenderness and paralumber muscle tenderness. However, Dr. Gerson reported only a five degree loss of flexion, the straight leg-raising test was negative, and the examination was not consistent with an acute lumbar radiculopathy.
Plaintiff complained to Dr. Gerson that he suffered from knee pain for two years. Tr. at 104. Plaintiff stated that his knees sometime get weak and give out, and he has difficulty with hills and steps. Plaintiff claimed that Tylenol gives him mild relief. However, Plaintiff offers no medical evidence that he has ever sought treatment for knee pain. Plaintiff did not recall ever having an x-ray, an injection into the knees, or seeing an orthopedic surgeon. Further, Plaintiff told Dr. Gerson that he did not have any swelling or locking of the knees. Id. Dr. Gerson's examination of Plaintiff revealed bilateral knee joint tenderness, but Plaintiff had full range of motion and no edema, crepitus, or joint instability. Dr. Gerson and Dr. Lizarraras opined that Plaintiff would be able to lift 50 pounds occasionally and 25 pounds frequently, stand and/or walk for 6 hours in an 8 hour work day, and sit for 6 hours in an 8 hour work day. Tr. at 117. Finally, both doctors opined that Plaintiff had no postural, manipulative, visual, communicative, or environmental limitations. Tr. at 113-115. Thus, Plaintiff's complaints of debilitating pain and disabling functional limitations are unsupported.
Second, in rejecting Plaintiff's subjective claims of pain and limitations, the ALJ identified specific, cogent reasons for the disbelief. Tr. at 16-17. The ALJ first found that none of Plaintiff's physicians have indicated Plaintiff suffered pain or dysfunction precluding him from all work activity for a period of at least 12 consecutive months. Tr. at 16. Second, on September 27, 2002, Dr. Tantuwaya reported that Plaintiff had made an excellent recovery after his subarachnoid hemorrhage and clipping of his right posterior communicating artery aneurysm. Tr. at 16-17. Third, on May 11, 2004, Dr. Gerson reported that Plaintiff was well-developed, well-nourished and in no acute distress. Tr. at 17. Fourth, on May 11, 2004, the claimant's blood pressure was 138/80. Fifth, Plaintiff's hypertension has been well controlled with no evidence of end-organ damage. Sixth, no functional significant neurological deficits have been described. Seventh, on May 11, 2004, Dr. Gerson opined that Plaintiff would be able [to] lift 50 pounds occasionally and 25 pounds frequently, stand and/or walk for 6 hours in an 8-hour work day, and sit for 6 hours in an 8-hour work day. Eighth, there is no objective medical evidence that Plaintiff is taking any medication that would impose disabling side effects, or any medication of potency commensurate with his reports of pain and limitations. Ninth, Plaintiff's complaints of pain and limitation are not supported by objective medical evidence. Finally, no treating physician has opined that Plaintiff was disabled. Id. Thus, the Court finds that the ALJ provided numerous, detailed reasons in support of the finding that Plaintiff was not credible.
Accordingly, the ALJ justified the decision to reject Plaintiff's claims with specific findings that are supported by the record. This Court finds that the ALJ did not arbitrarily discredit Plaintiff's allegations of pain and there is substantial evidence that Plaintiff's back, joint, and knee pain would not limit his ability to perform basic work functions.
4. Conclusion
Based on the reasons above, this Court finds that the ALJ's decision is supported by substantial evidence to support the conclusion that Plaintiff does not suffer from a severe impairment or a combination of impairments that have more than a minimal effect on the claimant's ability to work.
CONCLUSION AND RECOMMENDATION
After a thorough review of the record, the pleadings submitted by both parties and the authorities cited therein, this Court recommends that Plaintiff's motion for summary judgment be DENIED, and the Defendant's cross-motion for summary judgment be GRANTED. IT IS ORDERED that no later than April 28, 2006, any party to this action may file written objections with the Court and serve a copy on all parties. The document should be captioned "Objections to Report and Recommendation." IT IS FURTHER ORDERED that any reply to the objections shall be filed with the Court and served on all parties no later than May 12, 2006. The parties are advised that failure to file objections within the specified time may waive the right to raise those objections on appeal of the Court's order. Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991).