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Kinchen v. Colvin

United States District Court, E.D. Virginia, Richmond Division

December 20, 2016

FRANCES VANESSA KINCHEN, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          David J. Novak United States Magistrate Judge

         On July 12, 2010, Frances Vanessa Kinchen ("Plaintiff) applied for Social Security Disability Benefits ("DIB"), alleging disability from severe hypertension, depression and bipolar disorder, with an alleged onset date of April 14, 2009. The Social Security Administration ("SSA") denied Plaintiffs claims both initially and upon reconsideration. Thereafter, an Administrative Law Judge ("ALJ") denied Plaintiffs claims in a written decision and the Appeals Council granted Plaintiffs request for review. The Appeals Council remanded the claim for a new hearing and decision. An ALJ again denied Plaintiffs claims in a written decision, and the Appeals Council denied Plaintiffs second request for review, rendering the ALJ's decision as the final decision of the Commissioner.

         Plaintiff now seeks judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g), arguing that the ALJ erred in failing to give controlling weight to her treating physician's opinion. (Mem. in Support of Pl.'s Mot. for Summ. J. ("Pl.'s Mem.") (ECF No. 9) at 15-20.) Plaintiff further argues that the ALJ erred in failing to properly evaluate Plaintiffs credibility. (Pl.'s Mem. at 20-22.) Finally, Plaintiff argues that the ALJ erred in failing to adequately consider Plaintiffs obesity. (Pl.'s Mem. at 22-24.) This matter now comes before the Court for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B) on the parties' cross-motions for summary judgment and Plaintiffs motion for remand, rendering the matter now ripe for review.[1] For the reasons that follow, the Court recommends that Plaintiffs Motion for Summary Judgment (ECF No. 7) and Plaintiffs Motion for Remand (ECF No. 8) be DENIED, that Defendant's Motion for Summary Judgment (ECF No. 10) be GRANTED and that the final decision of the Commissioner be AFFIRMED.

         I. PROCEDURAL HISTORY

         On July 12, 2010, Plaintiff filed an application for DIB with an alleged onset date of April 14, 2009. (R. at 330-38.) The SSA denied these claims initially on January 7, 2011, and again upon reconsideration on April 13, 2011. (R. at 184-88, 190-92.) At Plaintiffs written request, the ALJ held a hearing on July 31, 2012. (R. at 69-89, 193-94.) On August 9, 2012, the ALJ issued a written opinion, denying Plaintiffs claims and concluding that Plaintiff did not qualify as disabled under the Act, because she could perform jobs that exist in significant numbers in the national economy. (R. at 163-78.) On October 17, 2013, the Appeals Council granted Plaintiffs request for review and remanded the claim for a new hearing and decision. (R. at 179-83.) A second ALJ held a hearing on March 7, 2014. (R. at 90-134.) On June 27, 2014, the ALJ again denied Plaintiffs claims in a written decision, and the Appeals Council denied Plaintiffs second request for review, rendering the ALJ's decision as the final decision of the Commissioner subject to review by this Court. (R. at 1-4, 46-59.)

         II. STANDARD OF REVIEW

         In reviewing the Commissioner's decision to deny benefits, a court "will affirm the Social Security Administration's disability determination 'when an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.'" Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015) (quoting Bird v. Comm V of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012)). Substantial evidence requires more than a scintilla but less than a preponderance, and includes the kind of relevant evidence that a reasonable mind could accept as adequate to support a conclusion. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). To determine whether substantial evidence exists, the court must examine the record as a whole, but may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472 (quoting Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005)). In considering the decision of the Commissioner based on the record as a whole, the court must "take into account whatever in the record fairly detracts from its weight." Breeden v. Weinberger, 493 F.2d 1002, 1007 (4th Cir. 1974) (quoting Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488 (1951)). The Commissioner's findings as to any fact, if substantial evidence in the record supports the findings, bind the reviewing court to affirm regardless of whether the court disagrees with such findings. Hancock, 667 F.3d at 477. If substantial evidence in the record does not support the ALJ's determination or if the ALJ has made an error of law, the court must reverse the decision. Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         The Social Security Administration regulations set forth a five-step process that the agency employs to determine whether disability exists. 20 C.F.R. § 416.920(a)(4); see Mascio, 780 F.3d at 634-35 (describing the ALJ's five-step sequential evaluation). To summarize, at step one, the ALJ looks at the claimant's current work activity. 20 C.F.R. § 416.920(a)(4)(i). At step two, the ALJ asks whether the claimant's medical impairments meet the regulations' severity and duration requirements. 20 C.F.R. § 416.920(a)(4)(ii). Step three requires the ALJ to determine whether the medical impairments meet or equal an impairment listed in the regulations. 20 C.F.R. § 416.920(a)(4)(iii). Between steps three and four, the ALJ must assess the claimant's residual functional capacity ("RFC"), accounting for the most that the claimant can do despite her physical and mental limitations. 20 C.F.R. § 416.945(a). At step four, the ALJ assesses whether the claimant can perform her past work given her RFC. 20 C.F.R. § 416.920(a)(4)(iv). Finally, at step five, the ALJ determines whether the claimant can perform any work existing in the national economy. 20 C.F.R. § 416.920(a)(4)(v).

         III. THE ALJ'S DECISION

         On March 7, 2014, the ALJ held a hearing during which Plaintiff (represented by counsel) and a VE testified. (R. at 90-134.) On June 27, 2014, the ALJ issued a written opinion, finding that Plaintiff did not qualify as disabled under the Act. (R. at 46-59.)

         The ALJ followed the five-step evaluation process established by the Social Security Act in analyzing Plaintiffs disability claim. (R. at 46-59.) At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since April 14, 2009. (R. at 51.) At step two, the ALJ found that Plaintiff had the following severe impairments: hypertension, atrial-septal defect of the heart with murmur and palpitations, obesity, bipolar disorder and post-traumatic stress disorder. (R. at 51.) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526. (R. at 51-53.)

         In assessing Plaintiffs RFC, the ALJ found that Plaintiff could perform light work as defined in 20 C.F.R § 404.1567(b) with certain exceptions. (R. at 53-57.) Specifically, the ALJ found that Plaintiff could sit for six hours and stand and/or walk for six hours during an eight-hour workday, but that she must alternate between sitting and standing in place every thirty minutes. (R. at 53.) Plaintiff could occasionally climb ramps and stairs, balance, stoop, kneel, crouch and crawl. (R. at 53.) Plaintiff could never climb ladders, ropes or scaffolds, and she must avoid all exposure to hazards including dangerous machinery and heights. (R. at 53.) Plaintiff must also avoid all exposure to temperature extremes and pulmonary irritants. (R. at 53.) Plaintiff could perform unskilled, non-production oriented work that involved no interaction with the public and only occasional interaction with co-workers and supervisors. (R. at 53.) At step four, the ALJ found that Plaintiff could not perform any past relevant work. (R. at 57-58.) At step five, the ALJ determined that Plaintiff could perform jobs existing in significant numbers in the national economy. (R. at 58-59.) Therefore, Plaintiff did not qualify as disabled under the Act. (R. at 59.)

         IV. ANALYSIS

         Plaintiff, thirty-nine years old at the time of this Report and Recommendation, previously worked as a certified nursing assistant. (R. at 125-27, 332, 372, 389-94.) She has also held positions as a cashier and convenience store clerk. (R. at 125-27, 372, 389-94.) Plaintiff applied for Social Security Benefits, alleging disability from severe hypertension, depression and bipolar disorder, with an alleged onset date of April 14, 2009. (R. at 330-38, 371.) Plaintiffs appeal to this Court argues that the ALJ erred in failing to give controlling weight to the opinion of her treating physician. (Pl.'s Mem. at 15-20.) Plaintiff further argues that the ALJ erred in failing to properly evaluate Plaintiffs credibility. (Pl.'s Mem. at 20-22.) Finally, Plaintiff argues that the ALJ erred in failing to adequately consider Plaintiff's obesity. (Pl.'s Mem. at 22-24.) For the reasons set forth below, the ALJ did not err in her decision.

         A. Substantial Evidence Supports the ALJ's Assignment of Weight to Dr. Spencer's Opinion Regarding Plaintiffs Physical Limitations.

         Plaintiff argues that the ALJ erred in failing to properly assign adequate weight to the opinion of her treating physician, Beverly Spencer, M.D. (Pl.'s Mem. at 15-19). Specifically, Plaintiff argues that the ALJ failed to sufficiently explain which evidence from the record that she found inconsistent with Dr. Spencer's opinion. (Pl.'s Mem. at 17.) Defendant responds that Dr. Spencer's opinion lacked support from the overall record, so the ALJ reasonably assigned it little weight. (Def.'s Mot. for Summ. J. & Br. in Support ("Def.'s Mem.") (ECF No. 10) at 14.)

         During the sequential analysis, when the ALJ determines whether the claimant has a medically-determinable severe impairment, or combination of impairments, that would significantly limit the claimant's physical or mental ability to do basic work activities, the ALJ must analyze the claimant's medical records that are provided and any medical evidence resulting from consultative examinations or medical expert evaluations that have been ordered. 20 C.F.R. §§ 404.1512(a)-(e), 404.1527, 416.912(a)-(e), 416.927. When the record contains a number of different medical opinions, including those from Plaintiff's treating sources, consultative examiners or other sources that comport with each other, then the ALJ makes a determination based on that evidence. 20 C.F.R. §§ 404.1520b(a), 416.920b(a). If, however, the medical opinions conflict internally with each other or other evidence, the ALJ must evaluate the opinions and assign them respective weight to properly analyze the evidence involved. 20 C.F.R. §§ 404.1527(c)(2)-(6), (e), 416.927(c)(2)-(6), (e).

         Under the applicable regulations and case law, a treating source's opinion deserves controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and does not conflict with other substantial evidence in the record. 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); Craig, 76 F.3d at 590; SSR 96-2p. Further, the regulations do not require that the ALJ accept opinions from a treating source in every situation, e.g., when the source opines on the issue of whether the claimant suffers from a disability for purposes of employment (an issue reserved for the Commissioner), or when the treating source's opinion lacks consistency with other evidence or when it otherwise lacks support. 20 C.F.R. §§ 404.1527(c)(3)-(4), (d), 416.927(c)(3)-(4), (d).

         Courts generally should not disturb an ALJ's decision as to the weight afforded a medical opinion absent some indication that the ALJ "dredged up 'specious inconsistences.'" Dunn v. Colvin, 607 F.App'x. 264, 267 (4th Cir. 2015) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1077 (7th Cir. 1992)). Indeed, an ALJ's decision regarding weight afforded a medical opinion should remain untouched unless the ALJ failed to give a sufficient reason for the weight afforded. 20 C.F.R. § 404.1527(d).

         The ALJ must consider the following when evaluating a treating source's opinion: (1) the length of the treating source relationship and frequency of examination; (2) the nature and extent of the treatment relationship; (3) supportability based upon the medical record; (4) consistency between the opinion and the medical record; (5) any specialization on the part of the treating source; and, (6) any other relevant factors. 20 C.F.R. §§ 404.1527(c), 416.927(c). However, those same regulations specifically vest the ALJ - not the treating source - with the authority to determine whether a claimant qualifies as disabled as the Act defines that term. 20 C.F.R. §§ 404.1527(d)(1), 416.927(d)(1). Although the regulations explicitly apply these enumerated factors only to treating sources, those same factors may apply in evaluating opinion evidence from "other sources." SSR 06-03p.

         Here, the ALJ considered Dr. Spencer's opinion in light of objective medical evidence and Plaintiffs subjective complaints. On June 14, 2012, Dr. Spencer diagnosed Plaintiff with hypertension, palpitations, heart murmur and atrial septal defect. (R. at 56, 833.) Dr. Spencer identified Plaintiffs prognosis as "good, " and opined that Plaintiff could sit for eight hours, but only stand or walk for one to two hours during an eight-hour workday. (R. at 56, 833-835.)

         Plaintiff could occasionally lift and carry up to twenty pounds, but she needed to avoid temperature extremes. (R. at 56, 835-37.) Dr. Spencer opined that Plaintiffs impairments would likely cause her to miss work two to three times per month. (R. at 833, 836.) The ALJ's assessment differed from Dr. Spencer's opinion in two ways. First, the ALJ concluded that Plaintiff could stand and/or walk for six hours in an eight-hour day, four to five more hours than Dr. Spencer opined. (R. at 53, 835.) Second, the ALJ did not find that Plaintiff would miss work two to three times per month due to her impairments. (R. at 53, 836.) Ultimately, the ALJ afforded little weight to Dr. Spencer's opinion, because the overall record did not support it. (R. at 56.) Substantial evidence supports the ALJ's decision.

         i. Internal Inconsistencies Exist Between Dr. Spencer's Opinion and Her Own Evaluation of Plaintiff.

         The inconsistency of Dr. Spencer's opinion with her own evaluation of Plaintiff supports the ALJ's assignment of weight. On February 6, 2012, Dr. Spencer conducted a physical evaluation of Plaintiff. (R. at 736-39.) Four months later, Dr. Spencer issued her opinion and diagnosis of Plaintiff based on that and previous evaluations. (R. at 833-38.) During the February evaluation, Dr. Spencer noted that Plaintiff had "been doing fairly well, " and indicated that Plaintiff had not recently undergone any lab work, imaging studies or tests. (R. at 736.) Dr. Spencer limited Plaintiffs ability to stand and walk to one to two hours in an eight-hour day, yet Plaintiff had denied any back, joint or muscle pain, muscle cramps or weakness. (R. at 738, 835.) Moreover, Plaintiff denied any tenderness, and Dr. Spencer found no swelling of Plaintiffs upper or lower extremities. (R. at 739.) In fact, Dr. Spencer instructed Plaintiff to exercise on a daily basis, consistent with recommendations from other doctors and medical professionals. (R. at 739, 863, 869, 924, 964, 1039.)

         Finally, Dr. Spencer premised her diagnosis on Plaintiffs subjective complaints of chest pain, shortness of breath, fatigue, palpitations and dizziness, as well as an unspecified edema; however, Plaintiff had denied any dizziness, fatigue or difficulty sleeping during her evaluation. (R. at 736-38, 833, 837.) On June 27, 2013, Plaintiff similarly denied the aforementioned symptoms, indicating neither limited mobility nor fatigue. (R. at 794-98.) Once again, Dr. Spencer instructed Plaintiff to exercise on a daily basis. (R. at 797.)

         In the absence of clinical evidence or laboratory diagnostic findings firmly supporting Dr. Spencer's opinion regarding Plaintiffs limitations, the ALJ reasonably assigned little weight to Dr. Spencer's opinion. See Craig, 76 F.3d at 590 (noting that a physician's opinion not supported by clinical evidence or laboratory test results, or otherwise inconsistent with other substantial evidence, should be accorded significantly less weight). Accordingly, the inconsistencies between ...


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