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Tammy Lynn B. v. Comm'r of Soc. Sec.
Citation: 382 F. Supp. 3d 184Docket: 5:18-CV-548
Court: District Court, N.D. New York; June 17, 2019; Federal District Court
Tammy Lynn B. has filed an action for review of the Commissioner of Social Security's final decision, which denied her applications for Supplemental Security Income (SSI) and Disability Insurance Benefits (DIB). Tammy initially applied for benefits on February 25, 2015, citing disabilities from back, right shoulder, and left foot injuries, claiming her disability began on February 21, 2014. Her applications were denied on May 13, 2015, prompting a hearing with Administrative Law Judge (ALJ) Jeremy G. Eldred on April 5, 2017, where she was represented by non-attorney Terry Schmidt, and testimony was provided by Vocational Expert Robert Baker. The ALJ ultimately denied her application for benefits in a decision dated May 4, 2017, which became final after the Appeals Council declined to review it. The court's review of the Commissioner's final decision is constrained to assessing whether it is backed by substantial evidence and whether the correct legal standards were applied. Substantial evidence is defined as relevant evidence that a reasonable mind would accept as adequate to support a conclusion. In reviewing the ALJ's findings, the court examines the entire record, considering both supporting and detracting evidence. If the determination is supported by substantial evidence, it is conclusive. The Commissioner's decision must be upheld even if it could be interpreted differently, unless there are reasonable doubts regarding the application of the appropriate legal standards. Disability under the Act is defined as the inability to engage in substantial gainful activity due to a medically determinable physical or mental impairment that is expected to last at least 12 months. For a claimant to be considered disabled, the impairment must be severe enough that the individual cannot perform previous work or any other substantial gainful work available in the national economy, regardless of job availability in their area or likelihood of employment. The ALJ follows a five-step evaluation process to determine disability. Step one assesses if the claimant has engaged in substantial gainful activity; if so, they are not disabled. Step two evaluates whether the claimant has a severe impairment that significantly limits basic work activities. If a severe impairment is present, step three checks if it meets or equals an impairment listed in the regulatory "Listings," which would result in the claimant being presumptively disabled. If not presumptively disabled, step four involves assessing whether the claimant has the residual functional capacity (RFC) to perform past relevant work, with the burden of proof on the claimant for the first four steps. If the claimant cannot perform past work, the burden shifts to the Commissioner in step five to demonstrate the claimant can engage in any type of work, considering factors like age, physical ability, education, and work experience. The Commissioner only needs to show that there is work in the national economy the claimant can perform, without needing to provide additional evidence of RFC. The ALJ applied a five-step disability determination process and concluded that Tammy had not engaged in substantial gainful activity since February 21, 2014. The ALJ found that Tammy's conditions—degenerative disc disease of the cervical and lumbar spine, right shoulder strain, and hallux valgus of the left foot—constituted severe impairments, but these did not meet or equal any Listings. At step four, the ALJ assessed that Tammy had specific exertional limitations, retaining the residual functional capacity (RFC) to perform sedentary work, but unable to reach overhead, limit head turning, or operate heavy machinery. Consequently, the ALJ determined that Tammy could not perform her past work as a convenience store clerk or cleaner/housekeeper. However, given her RFC, age, and limited education, she could perform jobs like charge account clerk, document preparer, microfilming, and call-out operator, which exist in sufficient numbers in the national economy. Thus, the ALJ denied Tammy's application for benefits. In her appeal, Tammy argued that the ALJ erred at step four by failing to adequately connect the evidence to the RFC determination. She claimed that the ALJ improperly evaluated medical evidence and did not sufficiently discuss treatment notes and opinion evidence. Additionally, she contended that the ALJ did not properly assess her credibility. It was noted that when an ALJ finds severe impairments but does not deem a claimant presumptively disabled, an RFC finding must still be made, evaluating what the individual can still do despite limitations. The RFC determination must incorporate the claimant's physical and mental abilities, symptomatology, and all relevant medical evidence, including credible testimony and medical opinions from various sources. Administrative law judges primarily rely on medical opinions and subjective testimony to evaluate work-related capabilities. Tammy criticizes the Administrative Law Judge (ALJ) for inadequately addressing the medical evidence, arguing that the ALJ's findings of "severe" impairments were unsupported by medical opinions that often indicated "no limitations." She contends that the opinions from treating providers did not fully reflect the limitations used in the Residual Functional Capacity (RFC) determination. The Regulations categorize medical evidence into three groups: treating, acceptable, and other sources, with treating sources—those who have an ongoing relationship with the claimant—being the most significant. A treating source's opinion is given controlling weight if it is well-supported by clinical evidence and consistent with other substantial evidence in the record. However, such opinions cannot solely determine disability status. When a treating source's opinion contradicts other evidence, the ALJ may assign it less weight. Factors for weighing treating sources include the length and frequency of the treatment relationship, the nature of that relationship, supporting evidence, consistency with the overall record, the physician's specialization, and any other relevant factors. The same criteria apply to acceptable and other sources, which include licensed medical professionals and ancillary providers, respectively. Only evidence from treating or acceptable sources can establish a medically determinable impairment, but all three categories can inform the severity of impairments and functional abilities. An ALJ is not required to explicitly cite these factors if the record demonstrates their proper consideration. Tammy's arguments regarding the ALJ's evaluation of medical evidence have been rejected. Firstly, there is a misunderstanding in her claim that the ALJ's step two finding of "severe" impairments is directly related to the step four RFC determination. Step two merely screens out trivial medical conditions, while step four evaluates functional limitations from all impairments, both severe and nonsevere. The ALJ is not required to adopt a specific RFC from any single medical opinion but can synthesize information from various sources. Although Tammy contends that the ALJ's RFC assessment contradicts certain medical opinions indicating minimal or no functional limitations, the ALJ is permitted to consider medical opinions alongside other evidence, including Tammy's own testimony, to determine a more restrictive RFC. The ALJ noted Tammy's reported difficulties with various physical activities, yet found that medical evaluations primarily indicated normal functionality. Ultimately, despite discrepancies between the ALJ's findings and individual medical opinions, the ALJ's comprehensive assessment of the evidence, including testimony and multiple medical sources, justifies the RFC determination. Tammy's disagreement with these findings does not warrant a remand. Tammy contends that the Administrative Law Judge (ALJ) improperly evaluated her credibility regarding her subjective pain and symptom experiences. An ALJ can reject subjective complaints after considering objective medical evidence, the claimant's demeanor, and other credibility indicators, provided that clear reasons are articulated to allow for a review of substantial evidence. If the medical evidence does not fully corroborate the claimant's testimony, the ALJ must apply a two-step analysis: first, assess if the medical impairments could reasonably produce the alleged pain or symptoms; second, evaluate the intensity, persistence, and limiting effects of those symptoms to determine their impact on the claimant's work ability. In this second step, the ALJ must consider various factors, including the claimant's daily activities, the characteristics of the pain, medication effects, other treatments, and any measures taken for relief. An ALJ's failure to address every regulatory factor does not necessitate remand if the rationale for credibility determination is sufficiently specific and demonstrates consideration of the entire evidentiary record. The ALJ's decision, while possibly lacking in detail regarding the rejection of Tammy's testimony, is not solely a brief paragraph but integrated with the medical evidence review. The ALJ acknowledged Tammy's claims of severe physical limitations and the effect of pain on her concentration but contrasted these with consistent normal findings from medical providers, thereby supporting the credibility assessment. Dr. Lorensen's report indicated that the plaintiff was capable of showering, dressing herself, and enjoyed fishing, alongside observations that she did not require assistive devices and could rise from a chair and get on or off the exam table without difficulty. These findings challenge the plaintiff's claims of extreme difficulty with daily activities. The ALJ considered the consistency of the plaintiff's testimony with past statements to healthcare providers, noting that Dr. Hines, the treating orthopedist, stated she could resume all daily activities and had no functional limitations. Similarly, her podiatrist reported no limitations following her recovery from foot surgery. The ALJ found that the evidence did not support the plaintiff's claims of concentration problems, as her treatment records indicated normal cognitive functioning and no functional limitations in daily living. Notably, the plaintiff attempted to fix her car's brakes, further questioning her claims of severe limitations. While individual pieces of evidence may not decisively undermine a claim of disability, collectively they suggest the plaintiff may not be as limited as asserted. The ALJ’s credibility findings are given significant deference, as they are in the best position to assess the demeanor and credibility of witnesses, making it difficult to overturn such findings unless they are patently unreasonable. Therefore, the argument against the ALJ's decision is rejected. The ALJ correctly applied the relevant legal standards and based his decision on substantial evidence. The court orders the following: Tammy's motion for judgment on the pleadings is denied, the Commissioner's motion for judgment on the pleadings is granted, the Commissioner's decision is affirmed, and Tammy's complaint is dismissed. The Clerk of the Court is instructed to enter judgment and close the case file. In compliance with local practice, only Tammy's first name and last initial are used in this opinion. The proceedings are treated as if both parties submitted motions for judgment on the pleadings. References to "R." denote the Administrative Record. The hearing was postponed to allow Tammy to secure representation. A note mentions the nature of her claim related to a bunion. It also states that the rules governing the evaluation of medical evidence changed on January 18, 2017, but prior policies apply to Tammy's claim since it was filed before March 27, 2017, with relevant case law cited regarding these changes.