Kelsey v. Comm'r of Soc. Sec.

Citation: 335 F. Supp. 3d 437Docket: 1:17-CV-00356 EAW

Court: District Court, W.D. New York; September 26, 2018; Federal District Court

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Plaintiff Denise Cecile Kelsey, represented by counsel, challenges the Acting Commissioner's final decision denying her application for disability insurance benefits under Title II of the Social Security Act. The Court has jurisdiction under 42 U.S.C. § 405(g). The parties have submitted cross-motions for judgment on the pleadings, with the Commissioner’s motion granted and the Plaintiff’s denied.

Kelsey filed her application for disability benefits on December 8, 2009, claiming a disability onset date of March 7, 2003, due to various medical conditions, including sleep apnea and depression. Initially denied on February 28, 2014, a hearing was conducted on July 24, 2013, resulting in an unfavorable decision. Upon Kelsey’s request, the Appeals Council vacated this decision on October 17, 2014, remanding the case for further evaluation, including obtaining evidence from a medical expert and a vocational expert.

A second hearing was held on April 16, 2015, where medical expert Dr. Donald Goldman provided testimony. Subsequently, ALJ Robert T. Harvey issued another unfavorable decision on June 11, 2015. The Appeals Council denied Kelsey’s request for review on July 1, 2015, making the ALJ's decision the final decision of the Commissioner.

In reviewing the Commissioner’s decision, the Court's role is limited to assessing whether the conclusions are supported by substantial evidence and based on the correct legal standards. Substantial evidence is defined as relevant evidence that a reasonable mind might accept as adequate to support a conclusion. The Court does not engage in a de novo determination of Kelsey’s disability status, as the Secretary's findings are conclusive if backed by substantial evidence, while legal conclusions are subject to different standards of review.

An ALJ utilizes a five-step sequential evaluation process to assess disability claims under the Act. Step one involves determining if the claimant is engaged in substantial gainful work activity; if so, the claimant is not disabled. If not, step two assesses whether the claimant has a severe impairment that significantly restricts basic work activities. If no severe impairment exists, the claimant is deemed "not disabled." If there is a severe impairment, step three checks if it meets or equals the criteria of a listed impairment in the regulatory Listings, and if it meets the durational requirement, the claimant is considered disabled. If it does not, the ALJ evaluates the claimant's residual functional capacity (RFC) to perform work activities despite limitations. Step four determines if the claimant can perform past relevant work based on their RFC; if they can, they are not disabled. If not, step five shifts the burden to the Commissioner to prove the claimant can engage in alternative substantial gainful work available in the national economy, considering the claimant’s age, education, and experience.

In the specific case of the Plaintiff, the ALJ confirmed that she last met the insured status requirements on December 31, 2006. At step one, it was concluded that the Plaintiff did not engage in substantial gainful work activity from the alleged onset date of March 7, 2003, to the date last insured. At step two, the ALJ identified severe impairments of obesity, discogenic lumbar spine, and lumbar radiculopathy, alongside non-severe impairments including sleep apnea, hypertension, gastroesophageal reflux disorder, and depression.

At step three, the ALJ determined that the Plaintiff did not have an impairment or combination of impairments that met or medically equaled any Listing's severity through the date last insured, particularly considering Listings 1.02 and 1.04 and the impact of Plaintiff's obesity as mandated by SSR 02-1p. Moving to step four, the ALJ assessed that Plaintiff retained the Residual Functional Capacity (RFC) to perform "light work" as defined by 20 C.F.R. 404.1567(b), with specific limitations: ability to lift no more than ten pounds, sit for two hours, and stand or walk for six hours in an eight-hour day, alongside occasional limitations in various physical activities and environmental conditions. At step four, the ALJ found no past relevant work for the Plaintiff. At step five, the ALJ, relying on a vocational expert, concluded that there were jobs available in significant numbers in the national economy that Plaintiff could perform, including usher, ticket taker, marker, and mail clerk. Consequently, the ALJ determined that Plaintiff was not disabled under the Act.

The Plaintiff's request for remand included claims that the ALJ's conclusions regarding Listings, morbid obesity, severe mental impairment, and the ability to perform work were unsupported by substantial evidence. However, the Court reviewed these arguments and found them without merit. The Court clarified that at step three, the ALJ must evaluate whether severe impairments meet or equal a Listing, with the understanding that listings describe severe impairments that prevent gainful activity. The ALJ is not always required to provide an explicit explanation unless evidence is in equipoise, which would necessitate credibility determinations and reasoning from the ALJ.

Plaintiff contends that the ALJ's determination at step three, which found Plaintiff's spinal impairment did not meet or equal Listing 1.04A, lacked substantial evidence. The Court disagrees, affirming that the ALJ provided a thorough rationale. The ALJ noted Dr. Donald Goldman's testimony, which suggested that Plaintiff's orthopedic impairments met specific Listings in combination. However, the ALJ assigned little weight to Dr. Goldman's opinion due to its internal inconsistencies, misalignment with Listing requirements, and reliance on treatment data postdating Plaintiff's last insured date. The ALJ further indicated that Plaintiff's impairments did not fulfill Listings 1.02 or 1.04A, citing the absence of evidence for muscle atrophy, sensory or reflex loss, effective ambulation, or the inability to perform normal activities. Knee pain reports were also deemed irrelevant as they occurred after the last insured date. The Court upheld the ALJ's discretion in evaluating medical opinions, particularly highlighting the internal inconsistencies in Dr. Goldman's testimony, which contradicted Listing 1.04A’s criteria for muscle and sensory loss. The ALJ acted appropriately by giving Dr. Goldman's opinion minimal weight.

The ALJ conducted a comprehensive review of medical evidence and determined that the Plaintiff's spinal impairment did not meet the criteria outlined in Listing 1.04A for nerve root compression. Listing 1.04A requires evidence of specific conditions, including motor loss with sensory or reflex loss and a positive straight-leg raising test if lower back involvement is present. Throughout the relevant period, the Plaintiff exhibited normal motor strength, sensation, and reflexes, leading the ALJ to reasonably conclude that the Plaintiff's condition did not satisfy Listing 1.04A requirements. The legal standard stipulates that all specified medical criteria must be met for a listing to be applicable, reinforcing the burden on the claimant to demonstrate full compliance with these criteria.

Additionally, the Plaintiff argued that the ALJ inadequately considered her obesity in assessing her limitations. However, the record does not support this claim. The ALJ is guided by SSR 02-1p, which requires consideration of obesity as a severe impairment if applicable. While the Plaintiff’s obesity was classified as "morbidly obese" and she reported difficulties related to her weight, Dr. Goldman noted a lack of objective findings to substantiate the claims that obesity significantly impacted her impairments, deeming the Plaintiff's assertions as subjective. The absence of explicit discussion regarding obesity does not constitute reversible error if there is no evidence of limitations in basic work activities due to it.

The ALJ evaluated the Plaintiff's obesity at each stage of the assessment. At step two, obesity was classified as a severe impairment. At step three, the ALJ assessed the impact of obesity on other impairments according to Social Security Ruling 02-1p but determined that the impairments did not meet or equal a Listing. The ALJ's Residual Functional Capacity (RFC) assessment included limitations related to the difficulties caused by obesity, such as restrictions in sitting, walking, standing, balancing, and climbing. The Court concluded that the ALJ adhered to SSR 02-1p and appropriately accounted for obesity's effects, noting that the Plaintiff did not provide evidence showing obesity caused limitations beyond those included in the RFC, thereby failing to meet her burden of proof regarding obesity-related limitations.

Regarding mental impairments, the Plaintiff claimed the ALJ erred by not recognizing a severe mental impairment, citing a history of depression and bipolar disorder, and argued that the ALJ did not adequately apply the "Paragraph B" criteria. The Court found this argument unpersuasive, explaining that the regulations require the ALJ to use a "special technique" to assess mental impairments by determining if a medically determinable impairment exists and rating functional limitations in four areas: daily living activities, social functioning, concentration, persistence, or pace, and episodes of decompensation. If limitations are rated mild or better and no episodes of decompensation are present, the impairment is generally deemed non-severe. The ALJ applied this technique appropriately in evaluating the Plaintiff's mental impairments.

The ALJ determined that the Plaintiff had a medically determinable mental impairment of depression but concluded that her mental impairments were non-severe based on an analysis of four functional areas. The findings included: (1) mild limitations in activities of daily living; (2) mild limitations in social functioning; (3) no limitations in concentration, persistence, or pace; and (4) no episodes of extended decompensation. The Plaintiff failed to demonstrate any errors in the ALJ's application of the special technique, specifically arguing that the ALJ did not assign proper weight to her activities of daily living. However, the ALJ's conclusion was supported by evidence showing that, despite receiving significant psychiatric treatment years prior, the Plaintiff sought no mental health treatment during the relevant period and only made occasional complaints of depression, maintaining a normal mood and affect.

During a temporary worsening of symptoms, her antidepressant dosage was increased, resulting in quick improvement. The Plaintiff also testified to engaging in various activities such as cooking, cleaning, scrapbooking, shopping, attending church, and visiting friends, which courts have deemed consistent with a finding of mild limitations in daily activities. The ALJ found some of her statements regarding limitations to be less than fully credible, noting inconsistencies in her testimony. The ALJ's credibility assessment is granted deference and can only be overturned if deemed patently unreasonable. The Court upheld the ALJ's findings, stating that the Plaintiff bore the burden to prove a severe mental impairment, which she did not do based on the evidence presented. Thus, the Court found no error in the ALJ's conclusion regarding the severity of the Plaintiff's mental impairment.

Plaintiff argues that the ALJ's step five analysis lacks substantial evidence due to the dismissal of Donald Shader's testimony and the inadequacy of hypothetical questions posed to VE Josiah Pearson. This claim is unsubstantiated. The Appeals Council vacated the ALJ's initial decision from the July 24, 2013, hearing due to issues with the consideration of VE Shader's testimony, and a subsequent hearing led to a new decision. Thus, Shader's testimony is irrelevant to the current case. The Plaintiff fails to explain how any error regarding Shader's testimony justifies a remand.

Regarding the hypothetical questions posed to VE Pearson, the Commissioner can rely on a vocational expert's testimony if the hypotheticals are based on substantial evidence. A hypothetical that omits any claimant limitations cannot be deemed substantial evidence for a conclusion of no disability. The Court found no error in the hypotheticals presented to VE Pearson, as they aligned with the RFC assessment and were supported by substantial evidence. The ALJ correctly determined that Plaintiff could perform a limited range of light work, citing imaging studies indicating only mild to moderate degenerative changes and normal motor strength, sensation, and reflexes. Plaintiff's conservative treatment yielded significant improvements, with reports of a 75% symptom reduction through physical therapy. The ALJ noted Plaintiff's credible statements about her pain and limitations, ultimately concluding that the evidence supported the capacity for limited light work based on medical evidence, treatment history, daily activities, and lack of supporting disability opinions.

An Administrative Law Judge (ALJ) is tasked with evaluating all available evidence to determine a claimant's Residual Functional Capacity (RFC) that aligns with the overall record. In this case, the ALJ determined that the Plaintiff could perform a limited range of light work, supported by medical findings indicating only minor physical impairments during the relevant period. The ALJ's conclusion was consistent with precedents allowing the review of medical imaging and other evidence to assess the severity of symptoms claimed by the Plaintiff. The ALJ properly formulated hypothetical scenarios for the vocational expert (VE) based on this assessment, excluding symptoms that were reasonably rejected. Consequently, the Court denied the Plaintiff's motion for judgment and granted the Commissioner's motion. The Clerk was instructed to finalize the judgment and close the case. Additionally, the Plaintiff's application for supplemental security income (SSI) was denied due to excess resources, a matter not under review in this Court. For Disability Insurance Benefits (DIB), a claimant must show they became disabled before their insured status expired, regardless of their current disability severity. The decision also referenced the "Paragraph B criteria" related to functional areas in adult mental disorders listings.