Opinion
Case Number 04-10041-BC.
April 13, 2005
The plaintiff filed the present action on February 20, 2004 seeking review of the Commissioner's decision denying the plaintiff's claim for a period of disability, disability insurance benefits, and supplemental security income benefits under Titles II and XVI of the Social Security Act. The case was referred to United States Magistrate Judge Charles E. Binder pursuant to 28 U.S.C. § 636(b)(1)(B) and E.D. Mich. LR 72.1(b)(3). Thereafter, the plaintiff filed a motion for summary judgment to reverse the decision of the Commissioner and award him benefits. The defendant filed a motion for summary judgment requesting affirmance of the decision of the Commissioner. Magistrate Judge Binder filed a report and recommendation on January 27, 2005 recommending that the plaintiff's motion for summary judgment be denied, the defendant's motion for summary judgment be granted, the findings of the Commissioner be affirmed. The plaintiff filed timely objections to the recommendation, to which the defendant responded, and this matter is now before the Court.
The Court has reviewed the file, the report and recommendation, the plaintiff's objections and the defendant's response thereto, and has made a de novo review of the administrative record in light of the parties' submissions. The plaintiff's objections echo the issues he raised in his motion for summary judgment, which were addressed by the magistrate judge. He now challenges the magistrate judge's conclusion that substantial evidence supports the decision of the Administrative Law Judge (ALJ) that the plaintiff is not disabled. In particular, the plaintiff contends the ALJ erred in concluding that the plaintiff could perform a limited range of sedentary work because the ALJ failed to give controlling weight to opinion of the plaintiff's treating physician, William Williams, D.O., and two medical reports from other physicians that corroborate the views of Dr. Williams. The plaintiff makes the three additional, related arguments: first, a hypothetical question posed by the ALJ to a vocational expert at the hearing failed to mention all of the plaintiff's work related limitations; second, the ALJ and magistrate judge failed to consider handwritten statements by Dr. Williams sent to the ALJ seven days before the hearing and included in the record; third, the ALJ and magistrate judge failed to consider as evidence the fact that the state of Michigan found the plaintiff disabled and awarded him state disability assistance.
The Court finds that the magistrate judge correctly decided the issues presented. Although there is evidence in the record that supports a finding that the plaintiff is disabled, the ALJ properly rejected it in favor of other substantial evidence that the plaintiff retained the functional capacity to perform gainful activity. Because the plaintiff therefore did not meet the disability requirements for benefits under Title II or XVI of the Act, his application properly was denied.
The plaintiff, who is now forty-nine, applied for a period of disability and disability insurance benefits on May 14, 2001, when he was forty-five years old. The plaintiff worked approximately three years as a truck driver and four years as the owner of an excavating business, which required him to operate heavy machinery. He last worked on June 12, 2000, which was the date he alleged his disability began as a result of a lower back disease. In his application, the plaintiff alleged that he was unable to work due to a lumbar degenerative disc disease with sciatica, marked by degeneration throughout the spine, some disc bulging, and numbness and pain in his legs. The application was denied and he made a timely request for a hearing. Meanwhile, he applied for supplemental security income benefits on December 26, 2001, and that application was advanced for consideration at the hearing. The ALJ made no determination as to the nondisability requirements under Title XVI, but in light of the finding on disability, that matter is inconsequential.
On March 21, 2003, the plaintiff appeared before ALJ John A. Ransom when he was forty-seven years old. ALJ Ransom filed a decision on April 25, 2003 in which he found that the plaintiff was not disabled. The ALJ reached that conclusion by applying the five-step sequential analysis prescribed by the Secretary in 20 C.F.R. §§ 404.1520, 416.920. The ALJ concluded that the plaintiff had not engaged in substantial gainful activity since June 12, 2000 (step one); the medical evidence in the plaintiff's case established that he has the "severe" impairments of degenerative disc disease and status post laminectomy and fusion at L4-5 (step two); neither of these impairments alone or in combination met or equaled a listing in the regulations (step three); and the plaintiff could not perform his previous work as a self-employed excavator, which was semi-skilled and required heavy exertion (step four).
In applying the fifth step, the ALJ concluded that the plaintiff had the residual functional capacity to perform a limited range of unskilled sedentary work. His limitations include no repetitive bending, twisting, turning or climbing, repetitive pushing or pulling with legs. The plaintiff could perform only simple and repetitive tasks of an unskilled nature with an option to sit or stand at will and consideration for use of a cane. A vocational expert testified that several jobs including assembler, machine operator, and sorter fit within those limitations. The ALJ found that those jobs existed in significant numbers in the regional economy. Using the Commissioner's medical vocational guidelines as a framework, see 20 C.F.R. Pt. 404, Subpt. P, App. 2 §§ 201.21 and 201.28, the ALJ found that the plaintiff was not disabled.
All parties agree with the magistrate judge that the plaintiff has the burden of proving disability in order to qualify for social security disability and supplemental security income benefits, and that "disability" is defined as the "inability to engage in any substantial gainful activity" due to a "physical or mental impairment" that could cause death or might reasonably be expected to last continuously for at least twelve months. See 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). Of course, a person is not disabled merely because his or her limitation prevents the person from performing previous work, if that person can perform other "substantial gainful work which exists in the national economy." 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B). The parties also accept the rule that the authority of this Court to review administrative decisions of the Commissioner is limited to deciding whether the proper legal standards were used and "whether there is substantial evidence in the record to support the findings." Wright v. Massanari, 321 F.3d 611, 614 (6th Cir. 2003) (quoting Duncan v. Sec'y of Health Human Servs., 801 F.2d 847, 851 (6th Cir. 1986)). The plaintiff takes issue with the application of this rule, however, arguing that the magistrate judge and the ALJ culled from the record only that evidence which favored a determination of no disability, violating the familiar instruction that a decision can not be based on a single piece of evidence in disregard of other pertinent evidence that exists in the record, see Hephner v. Matthews, 574 F.2d 359, 362 (6th Cir. 1978), and that "the substantiality of evidence must take into account whatever in the record fairly detracts from its weight." Garner v. Heckler, 745 F.2d 383, 388 (6th Cir. 1984). The plaintiff argues that there is substantial evidence in the record from Dr. Williams establishing that the plaintiff is disabled, and that evidence is corroborated by post-hearing, post-decision records that ought to be considered by this Court.
But that is not the proper standard. The Commissioner's findings are conclusive if they are supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971); see also Lashley v. Sec'y of Health Human Servs., 708 F.2d 1048, 1053 (6th Cir. 1983). The Court "may not try the case de novo, nor resolve conflicts in evidence, nor decide questions of credibility." Garner, 745 F.2d at 387. Nor may the Court receive new evidence, except, perhaps, to consider the narrow issue of whether the case ought to be remanded for expansion of the administrative record and reconsideration, a remedy the plaintiff has not requested here. See Cline v. Commissioner of Social Sec., 96 F.3d 146, 148 (6th Cir. 1996) (holding that "the district court cannot consider that new evidence in deciding whether to uphold, modify, or reverse the ALJ's decision").
The evidence in the administrative record in this case shows that the plaintiff suffered low back pain and numbness in his legs as early as the summer of 2000. Dr. Williams, the plaintiff's family doctor, referred him to Dr. John DiBella, who engaged in a course of conservative treatment that included epidural steroid injections in lumbar region. The plaintiff eventually was referred to Dr. Field, who performed a decompressive laminectomy and fusion on June 6, 2001. The plaintiff was followed after surgery by Dr. Field and Dr. Akbar, a neurosurgeon. Their findings are recounted by the magistrate judge in his report and need not be repeated here. It is sufficient to observe that the plaintiff's course of healing was slow, but Drs. Field and Akbar documented normal or mildly abnormal findings over the next several months.
The plaintiff also received follow-up care from Dr. Williams, who had treated him from a young age. Dr. Williams believed in July 2001 that the plaintiff would be disabled for at least six months but he was improving, although the doctor felt that the plaintiff would never go back to heavy work. Tr. at 284-85. By August 2002, Dr. Williams was of the opinion that the back surgery helped but did not correct the plaintiff's problem; physical therapy was not effective; and the plaintiff was "disabled with this pain." Tr. at 305. Dr. Field's treatment notes end as of August 7, 2001 — two months after surgery — at which time the doctor's opinion was that the plaintiff needed a back brace for three to four months and would be disabled until he shed his brace and was rehabilitated. Tr. at 219. Dr. Akbar's last note is dated January 24, 2002 and states that the plaintiff was "ambulating satisfactorily," clinical tests were "satisfactory," and X-rays showed that his lumbar fusion had "healed satisfactorily." Tr. at 242. However, the plaintiff still had symptoms and Dr. Akbar ordered a MRI. Ibid. Neither Dr. Field nor Dr. Akbar performed a functional assessment.
The Commissioner's case is not particularly compelling. For instance, the ALJ concluded that the plaintiff could perform a limited range of sedentary work, which at a minimum consists of "lifting no more than ten pounds at a time and occasionally carrying articles like docket files, ledgers, and small tools," 20 C.F.R. § 404.1567(a) (2002), and "periods of standing or walking [that] generally total no more than 2 hours of an 8-hour work day, and sitting [that] generally total approximately 6 hours of an 8-hour work day." Social Security Ruling (SSR) 83-10. No physician specifically stated that the plaintiff could perform these exertional tasks. However, the ALJ inferred this capability from the reports of treating specialists Dr. Akbar (the orthopedic surgeon) and Dr. Field (the neurosurgeon). They reported normal clinical findings after surgery upon performing the standard clinical tests, and the diagnostic studies disclosed no gross abnormalities except those associated with the plaintiff's back surgery. For instance, the MRI of the lumbar spine on October 7, 2002 showed degenerative changes and a bulging disc but characterized these findings as "mild" and showed no nerve root impingement, spinal stenosis, or herniation. The ALJ, as the fact finder, is permitted to make these inferences even though a contrary inference also is supported by substantial evidence.
In this case, the plaintiff's treating family physician, Dr. Williams, stated on two occasions that the plaintiff was "totally and permanently disabled." The ALJ discounted that opinion because it was contradicted by a statement by the plaintiff to Dr. Akbar that he was "walking quite a bit," see Tr. at 18, and not confirmed by the objective medical tests or the clinical findings of Drs. Field and Akbar, and Dr. Williams made no clinical findings of his own that supported his opinion.
The Sixth Circuit recently has held that reversal is required in a Social Security disability benefits case where the ALJ rejects a treating physician's opinion as to the restrictions on a claimant's ability to work and fails to give good reasons for not giving weight to the opinion. Wilson v. Comm'r of Social Sec., 378 F.3d 541, 544 (6th Cir. 2004). There, the court stated that "pursuant to [ 20 C.F.R. § 404.1527(d)(2)], a decision denying benefits `must contain specific reasons for the weight given to the treating source's medical opinion, supported by the evidence in the case record, and must be sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight.'" Id. at 544 (quoting Soc. Sec. Rul. 96-2p, 1996 WL 374188, at *5 (1996)).
The ALJ in this case gave reasons for rejecting Dr. Williams' opinion on disability. A treating physician's opinion may be rejected if there is good reason to do so. Hall v. Bowen, 837 F.2d 272, 276 (6th Cir. 1988). The Sixth Circuit has held that treating physicians' opinions "are only given such deference when supported by objective clinical evidence." Warner v. Comm'r of Soc. Sec., 375 F.3d 387, 390 (6th Cir. 2004) (citing Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 477 (6th Cir. 2003). Where a treating physician renders an opinion using legal language as opposed to medical terminology, the Court may likewise reject it if it is not supported by clinical evidence in the record. See Casey v. Sec'y of Health Human Servs., 987 F.2d 1230, 1234-35 (6th Cir. 1993). The ALJ gave reasons for rejecting the opinion of the treating source in this case, and the reasons are supported by the evidence in the administrative record.
The Court concludes, therefore, that the magistrate judge correctly observed that the ALJ's residual functional capacity was within the "zone of choice" supported by substantial evidence. Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986) (en banc).
Since the ALJ's residual functional capacity assessment is supported by the evidence, his hypothetical question to the vocational expert likewise is proper. The rule that a hypothetical question must incorporate all of the claimant's physical and mental limitations does not divest the ALJ of his or her obligation to assess credibility and determine the facts. In fashioning the hypothetical question to be posed to the vocational expert, the ALJ "is required to incorporate only those limitations accepted as credible by the finder of fact." Casey, 987 F.2d at 1235. "[A]n ALJ is not required to accept a claimant's subjective complaints and may properly consider the credibility of a claimant when making a determination of disability," and "can present a hypothetical to the [vocational expert] on the basis of his own assessment if he reasonably deems the claimant's testimony to be inaccurate." Jones, 336 F.3d at 476 (6th Cir. 2003).
After a de novo review of the entire record and the materials submitted by the parties, the Court concludes that the magistrate judge properly reviewed the administrative record and applied the correct law in reaching his conclusion. The Court has considered all of the plaintiff's objections to the report and finds them to lack merit.
Accordingly, it is ORDERED that the magistrate judge's report and recommendation is ADOPTED.
It is further ORDERED that the plaintiff's motion for summary judgment [dkt # 14] is DENIED.
It is further ORDERED that the defendant's motion for summary judgment [dkt # 18] is GRANTED. The findings of the Commissioner are AFFIRMED, and the complaint is DISMISSED.