Court: District Court, D. Arizona; January 10, 2019; Federal District Court
David G. Campbell, Senior United States District Judge, reviews the final decision by the Commissioner of Social Security denying G.A. Leusch's disability insurance benefits and supplemental security income. Leusch, a 55-year-old with a ninth-grade education and prior experience as a cabinet maker, applied for benefits on September 24, 2013, citing a disability onset of June 20, 2012. Following hearings with a vocational expert and a medical expert, the ALJ issued an unfavorable decision on September 28, 2016, which became final after the Appeals Council denied review on February 13, 2018.
The Court's review is limited to issues raised by Leusch. It may overturn the Commissioner's decision only if it lacks substantial evidence or is legally flawed. Substantial evidence is defined as relevant evidence sufficient for a reasonable person to accept as adequate. The Court must evaluate the entire record and cannot affirm based solely on isolated evidence. The ALJ is tasked with resolving medical testimony conflicts, assessing credibility, and clarifying ambiguities.
The ALJ employs a five-step evaluation process to determine disability under the Social Security Act. The claimant bears the burden of proof for the first four steps, after which the burden shifts to the Commissioner. In the first step, the ALJ assesses if the claimant is engaged in substantial gainful activity; if so, the inquiry ends. The second step involves determining if the claimant has a severe medical impairment. The third step checks if the impairment meets or equals listed impairments. If neither step leads to a determination of disability, the ALJ evaluates the claimant's residual functional capacity (RFC) in step four to see if they can perform past relevant work, concluding the inquiry if they can.
The ALJ's evaluation of the claimant's disability status follows a five-step process as outlined in 20 C.F.R. 404.1520(a)(4)(v). At step one, the ALJ confirmed that the claimant met the insured status requirements through June 30, 2014, and had not engaged in substantial gainful activity since June 20, 2012. At step two, the ALJ identified several severe impairments: bilateral carpal tunnel syndrome, history of left cubital tunnel syndrome, lumbar spine spondylosis, and cervical spine spondylosis. At step three, the ALJ found that the claimant's impairments did not meet or medically equal a listed impairment. At step four, the ALJ assessed the claimant's Residual Functional Capacity (RFC) to perform medium work, including the ability to lift and carry specified weights, sit with breaks, and stand or walk for six hours. Consequently, the ALJ concluded that the claimant could perform past relevant work as a cabinet maker and was not disabled from June 20, 2012, to September 28, 2016.
The claimant argues the ALJ's decision is flawed for two reasons: (1) the rejection of assessments from treating physicians, Dr. Kearney and Dr. Amrani, while favoring the opinion of non-examining physician Dr. Schmitter, and (2) a lack of specific, clear, and convincing reasons for dismissing the claimant's symptom testimony.
Regarding medical opinions, the standard dictates that an ALJ generally should give the most weight to treating physicians and more weight to examining physicians than to non-examining ones. If a treating physician's opinion is not contradicted, it can only be rejected for clear and convincing reasons. In this case, the ALJ assigned little weight to Dr. Kearney's opinion, which is permissible if the ALJ provides specific and legitimate reasons supported by substantial evidence.
On May 29, 2015, Dr. Kearney assessed the Plaintiff, noting moderately severe pain affecting his functionality and ability to work. He identified impairments including carpal tunnel syndrome, cubital tunnel syndrome, cervical radiculopathy, and lumbar radiculopathy. Dr. Kearney opined that in an eight-hour workday, the Plaintiff could sit for six hours, stand and walk for 2-3 hours, lift 10-15 pounds, could not use his left hand, could frequently use his right hand, and had various limitations on other physical activities. On September 23, 2015, Dr. Kearney updated his opinion to reflect that the Plaintiff had both right and left carpal tunnel syndrome, stating he could sit for six hours, stand and walk for six hours, lift 15-20 pounds, and carry 20-30 pounds, with restrictions noted as beginning June 20, 2012. He later clarified that the Plaintiff would need breaks after using his hands. The Administrative Law Judge (ALJ) assigned little weight to Dr. Kearney's opinions, citing two reasons: a lack of supporting medical records for the severity of limitations and Dr. Kearney's specialty as a nonsurgical sports and family medicine practitioner.
Regarding the first reason, the ALJ highlighted physical examination results that showed negative Tinel's and Phalen's tests and normal sensation in the left hand. The ALJ referenced medical records from two visits; during the first visit on September 23, 2015, the Plaintiff reported severe pain in both hands, and the assessment noted ongoing symptoms of carpal tunnel syndrome. The second visit on November 4, 2015, indicated continued pain and conflicting evidence about the source of symptoms, with a positive Durkan's test and decreased sensation. The Plaintiff contends that the ALJ's cited records actually support Dr. Kearney's opinions, pointing out that Dr. Kearney's findings and the subsequent examination results remained consistent with the Plaintiff's reported symptoms. The ALJ did not adequately explain how the examination results contradicted Dr. Kearney's assessments.
The November examination of the Plaintiff's right hand showed negative results for Tinel's, Phalen's, and Spurling's tests, but positive results for Durkan's test, Tinel's at the elbow, and elbow flexion, along with decreased sensation in the left median, ulnar, and radial distributions. The ALJ did not explain the significance of these mixed findings and failed to articulate why his interpretation was correct over Dr. Kearney's assessment, which he deemed unsupported. Although the ALJ provided a detailed record discussion, he did not specifically address evidence that supported or contradicted Dr. Kearney's opinion.
The ALJ also discredited Dr. Kearney's opinion based on his specialization in sports and family medicine rather than surgical practice, while the medical expert (ME) was board-certified in orthopedic surgery. The Defendant did not defend this rationale, and while specialization is a consideration in evaluating medical opinions, it is not definitive. The ALJ must consider the extent of examinations and tests performed by the treating source, and Dr. Kearney's qualifications alone were insufficient grounds for discrediting his opinion.
Regarding Dr. Jacob Amrani, who is a treating physician, the ALJ assigned little weight to his opinion, which stated that the Plaintiff's spinal impairments prevented him from working a full eight-hour day. Dr. Amrani indicated limitations on sitting, standing, walking, lifting, and carrying, and noted that the Plaintiff would need to alternate positions frequently and could be off task due to moderate pain. The ALJ provided three reasons for discounting Dr. Amrani's opinion: (1) the Plaintiff's post-surgery examination results were 'relatively normal,' (2) Dr. Amrani reported benign findings and referred the Plaintiff for pain management, and (3) the Plaintiff's use of marijuana for pain relief raised questions about his credibility regarding its medical use. The ALJ cited normal findings such as full range of motion and a negative straight leg raising test to support his reasoning, while the Plaintiff maintained that his examinations revealed positive objective findings following his cervical surgery.
Plaintiff presents medical examinations indicating limited and painful cervical and lumbar motion, tenderness in the spine and occipitals, decreased sensation in both hands, positive straight leg raise tests, and a noticeable limp. Medical records show mixed results; a June 2012 MRI revealed mild to moderate disc bulges and stenosis at various lumbar levels. November 2013 notes indicate physical therapy had no effect on Plaintiff's pain, with some range of motion limitations but no neurological abnormalities or significant stenosis. In 2014, Plaintiff underwent multiple spinal procedures, including branch blocks and ablations. By March 2015, ongoing issues with cervical disc displacement and lumbar stenosis were noted, yet there was normal gait and strength. Following continued pain, spinal fusion surgery was performed in April 2015. May and July 2015 evaluations showed varying degrees of pain and motion, with an MRI revealing mild degenerative changes but stable findings. Ongoing pain was reported in August 2015, and a January 2016 spinal cord stimulator trial was deemed ineffective. March 2016 assessments indicated full motion in the spine with some tenderness requiring treatment. The ALJ found insufficient support for Dr. Amrani's opinion, with the ME concluding that the cervical fusion was unlikely to improve Plaintiff's condition due to the absence of neurological deficits pre-surgery, which the ALJ deemed an inadequate reason for discrediting Dr. Amrani’s opinion, as the ME's treatment perspective was not relevant to the evaluation of evidence.
The ALJ rejected Dr. Amrani’s opinion that the Plaintiff could only stand and walk for two hours, agreeing instead with the ME's assessment. However, the ALJ improperly focused on a single finding from a four-year medical history to discredit Dr. Amrani's opinion, failing to provide specific and legitimate reasons for doing so. The ALJ reviewed treatment notes from September 2015 to March 2016, which yielded mixed results regarding the Plaintiff's condition, yet did not interpret this evidence thoroughly. The ALJ’s claim that objective evidence did not support Dr. Amrani's opinion was deemed inadequate. The ME diagnosed the Plaintiff with chronic cervical and low back pain, allowing for more extensive physical activity than Dr. Amrani suggested. The ALJ justified favoring the ME's opinion based solely on reduced findings post-cervical fusion surgery but acknowledged that these findings were also mixed. The ALJ overstepped by substituting her judgment for that of medical professionals, neglecting to provide comprehensive interpretations of the medical evidence. Additionally, the ALJ criticized Dr. Amrani for benign findings and referrals for pain management without adequately explaining how these factors undermined Dr. Amrani's opinion regarding the Plaintiff's work-related limitations. The ALJ's reasoning failed to constitute a specific and legitimate basis for discounting the treating physician’s opinion as mandated by legal precedents.
The ALJ noted that the Plaintiff's use of marijuana for pain management raised questions, particularly due to inconsistent testimony regarding whether it was medical marijuana. The ALJ failed to provide a clear rationale for discrediting Dr. Amrani's treating assessment based on the Plaintiff's marijuana use and did not present evidence indicating that Dr. Amrani's opinion relied solely on self-reported information rather than clinical evidence. The ALJ's reasoning was deemed insufficient to discredit Dr. Amrani's opinion.
In evaluating the Plaintiff's symptom testimony, the ALJ was required to perform a two-step analysis. First, the ALJ had to establish whether objective medical evidence supported an impairment that could reasonably cause the alleged symptoms. The Plaintiff needed only to demonstrate that his impairment could lead to some symptoms, not the full severity claimed. Second, absent evidence of malingering, the ALJ could only reject the Plaintiff's symptom testimony with specific, clear, and convincing reasons. The Plaintiff described experiencing constant pain and pressure in his neck and lower back, with pain radiating into his legs and numbness from his knees to his feet. He reported exacerbation of pain from various activities and noted that common pain relief methods, like aspirin, were ineffective. The Plaintiff also indicated that prior surgeries and injections did not provide lasting relief.
His daily activities included minimal household chores and limited mobility, as he could stand for only 15-20 minutes, sit for an hour, and walk approximately 100 yards before needing rest. He estimated sleeping only about two hours a night due to pain. The ALJ concluded that the Plaintiff's symptom testimony conflicted with his daily activities and the medical evidence presented.
In assessing the claimant's testimony, the ALJ is permitted to identify inconsistencies between the claimant's statements and their daily activities, as established in Molina v. Astrue. While the claimant does not need to demonstrate total inactivity to qualify for benefits, the ALJ can discredit testimony if everyday activities imply a level of functional capacity that contradicts claims of severe impairment. The ALJ noted that although the claimant's daily activities were limited, certain abilities demonstrated were indicative of potential employment capabilities. Activities such as household chores, meal preparation, driving, and socializing were cited as inconsistent with the claimant's assertions of debilitating limitations. However, the ALJ did not find evidence of malingering nor provided specific details on which activities contradicted the claimant’s testimony. Instead, the ALJ offered a general summary of the claimant's activities followed by a lengthy discussion of medical evidence, lacking clarity on the credibility determination. The Defendant conceded that the activities alone do not prove the ability to work but argued they were inconsistent enough to justify the ALJ's credibility assessment. The Court, however, emphasized that it cannot infer inconsistencies without specific explanations from the ALJ, highlighting that the nature of daily activities differs significantly from full-time work. The Ninth Circuit requires that ALJs cite specific testimony that lacks credibility based on factual evidence. The ALJ's failure to provide clear and convincing reasons for discrediting the claimant’s symptom testimony based on daily activities was noted as a significant oversight.
Pain severity resulting from a medically diagnosed abnormality can substantiate a claimant's disability status. A claimant must present objective medical evidence of an underlying impairment, but an Administrative Law Judge (ALJ) cannot dismiss subjective pain complaints solely due to a lack of corroborating objective evidence. Objective evidence of the pain's existence or its severity is not required, nor is evidence establishing a direct causal link between the impairment and symptoms. The regulations and judicial precedents emphasize that a claimant's statements regarding pain intensity and its impact on work cannot be rejected purely on the basis of insufficient objective medical support.
If an ALJ finds a claimant not credible, this must be based on affirmative evidence of malingering or specific, clear, and convincing reasons. General statements are inadequate; the ALJ must specify which testimony is deemed not credible and the evidence that contradicts the claimant's complaints.
In this case, regarding hand and wrist pain, the ALJ referenced only two examinations from a four-year medical history, which the court deemed insufficient for discrediting the claimant's symptom testimony. For neck and back pain, the ALJ noted some positive findings post-cervical fusion surgery but failed to adequately address the claimant's reported symptoms, including significant pain levels and limitations in daily activities. The court found that the ALJ selectively used limited evidence to support his credibility determination, overlooking the claimant's self-reported pain levels and the effects on his ability to function.
The Court found that the ALJ did not provide specific, clear, and convincing reasons to discredit the Plaintiff's pain testimony, despite a four-year history of pain and extensive medical treatment, including MRIs, nerve blocks, and a spinal fusion. The Vocational Expert (VE) indicated that the Plaintiff's symptoms would prevent him from performing past work. The ALJ also erred in dismissing the opinions of Drs. Kearney and Amrani regarding Plaintiff's symptoms. Plaintiff argues for a remand to award benefits based on this evidence, while the Defendant suggests further proceedings are necessary. Typically, when an ALJ denies benefits and a court identifies an error, remand for further proceedings is standard unless a “rare exception” applies, which allows for an immediate award of benefits if a three-part analysis known as the "credit-as-true" rule is satisfied.
The analysis first considers if the ALJ provided insufficient reasons for rejecting evidence. Next, it checks for unresolved issues that might affect the disability determination and whether further administrative action would be beneficial. If both conditions are met, the discredited testimony is accepted as true to assess if there’s no doubt regarding disability. However, even at this third stage, the Court retains the discretion to remand for further proceedings if the record lacks clarity.
Regarding Plaintiff's hand and wrist conditions, the Court noted doubts about his disability status. Dr. Kearney suggested that Plaintiff could use his hands very minimally, implying severe carpal tunnel syndrome. However, the Medical Expert (ME) disagreed, citing a lack of confirming diagnostic studies and no significant findings of severe numbness. The ME noted that previous treatments showed improvement in the left hand post-surgery and no evidence of right carpal tunnel syndrome. Follow-up examinations indicated normal findings for both hands, with instructions to resume regular activities.
In May 2015, Dr. Kearney's examination indicated that Plaintiff's hands were normal, showing no swelling, tenderness, or deformity, with full range of motion and strength. By September 2015, some abnormal sensation in the left hand was noted, but other tests showed normal results, suggesting improvement from prior carpal tunnel syndrome after surgery. The evidence did not support significant issues in the right hand as opined by Dr. Kearney, raising doubts about the severity of Plaintiff's hand and wrist conditions.
Regarding Plaintiff's neck and back conditions, Dr. Amrani assessed that Plaintiff could sit for six hours, stand or walk for two, and needed to alternate positions frequently. Plaintiff reported persistent pain, exacerbated by movement, and testified about needing to lie down multiple times daily for relief. During the hearing, it was established that if Plaintiff’s condition necessitated resting, he could not perform his past work or any other employment.
The Court found no unresolved issues regarding Plaintiff's disability, noting a comprehensive medical record of ongoing pain, treatments, and specialist referrals over four years. If Dr. Amrani's assessment and Plaintiff's testimony are accepted, the vocational expert’s testimony indicated that Plaintiff could not work. Consequently, the Court determined that remanding for an award of benefits was justified, vacating the Commissioner of Social Security's decision. The ALJ acknowledged changed circumstances since a prior finding of nondisability in June 2012 and determined that the previous conclusions were not preclusive. The ALJ's consideration of Plaintiff's daily activities in relation to competitive work and the defendant’s assertion regarding conservative treatment were also noted, with the Court emphasizing that the ALJ did not explicitly cite conservative treatment as a basis for discounting Plaintiff's testimony.
