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Michael v. Berryhill

United States District Court, M.D. Pennsylvania

January 3, 2018

NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.


          Martin C. Carlson United States Magistrate Judge.

         I. Introduction

         Plaintiff Miranda D. Michael (“Ms. Michael”), an adult individual who resides within the Middle District of Pennsylvania, seeks judicial review of the final decision of the Acting Commissioner of Social Security (“Commissioner”) denying her claims for Disability Insurance Benefits and Supplemental Security Income under Titles II and XVI of the Social Security Act. In this Social Security Appeal, Michael advances one primary claim of error alleging that the Administrative Law Judge (“ALJ”) failed to accord greater weight to her treating physician's opinion than to the opinion of a non-treating, non-examining state agency physician. (Doc. 15 p. 8.) She argues that, in turn, because the ALJ failed to adopt her treating physician's opinion, the Step 5 determination that Michael was not disabled is unsupported by substantial evidence. (Doc. 15 p. 14.) In the instant case, the ALJ reviewed the medical opinion of Ms. Michael's treating physician, which concluded that Ms. Michael was disabled, and the opinion of a state agency medical source, which found that she retained the residual functional capacity to perform a range of light work with limitations. The ALJ resolved the case at Step 4 and concluded that Ms. Michael was not disabled because her residual functional capacity enabled her to return to her past relevant work.

         Given the deferential standard of review that applies to Social Security Appeals, which calls upon us to simply determine whether substantial evidence supports the ALJ's findings, we conclude that substantial evidence does exist in this case, which not only justified the ALJ's evaluation of the medical opinion evidence, but justified Ms. Michael's residual functional capacity. Therefore, for the reasons set forth below, the Commissioner's decision is affirmed, and Ms. Michael's request for relief is denied.

         II. Statement of Facts and of the Case

         On September 20, 2012, Ms. Michael protectively filed applications for disability benefits under both Title II and XVI of the Social Security Act. In Ms. Michael's Title II and Title XVI applications, she alleged that she had been disabled since June 7, 2012. (Tr. 149; 151.)[2] According to Ms. Michael, her claim of disability is based upon a series of aliments including anemia, a rare lung disease, diabetes, extreme weight loss, and pneumonia. (Tr. 179.) At the time of Ms. Michael's applications, and the onset of her alleged disability, she was in her late 50's and was considered an individual of “advanced age” according to the regulations promulgated under the authority of the Act. (Tr. 54.) See 20 C.F.R. §404.1563(e). Ms. Michaels is a high school graduate and attended Consolidated School of Business.[3] (Tr. 41.) Her work history report includes employment spanning from 2001 through 2012, in which she was employed as a collections representative and an administrative secretary. (Tr. 190.)

         Ms. Michael's health ailments related to her disability claims began in early 2012. In January 2012, Ms. Michael presented to Memorial Hospital's emergency department with shortness of breath, chest pain, and a cough. (Tr. 257-258.) Ms. Michael was admitted and treated for pneumonia. (Id.) At her two week follow up, Ms. Michael reported she was feeling better but complained of decreased energy, fatigue, and unexplained weight loss. (Tr. 360.) After testing, Ms. Michael was diagnosed with pulmonary nodules and underwent video-assisted thoracoscopic surgery (“VATS”) in June 2012. (Tr. 433; 421.) Ms. Michael started taking Prednisone, an oral steroid, to treat her pulmonary condition. (Tr. 543.) By September 2012, after continuing treatment with Prednisone, Ms. Michael's pulmonary condition was improving, she was no longer losing weight, and she was less symptomatic. (Tr. 317.) Ms. Michael reported she was continuing to feel well and exercising sporadically (Tr. 386) and that her appetite was significantly improving. (Tr. 603.)

         Eight months later Ms. Michael was admitted into York Hospital from May 6, 2013 through May 11, 2013 after presenting with chest pain. (Tr. 621-622.) A CT scan revealed an increasing mass in her left lung. (Tr. 642.) Ms. Michael informed the treating doctor that steroids had helped her in the past and steroids were administered. (Tr. 642; 644.) By the following month, Ms. Michael's symptoms had improved and she was starting to feel better. (Tr. 581.) She had gained 32 pounds since November 2012. (Tr. 666.) Unfortunately, in August 2013, Ms. Michael suffered a heart attack and successfully underwent a stent procedure in her right coronary artery. (Tr. 875.) The doctor that performed her surgery believed if Ms. Michael began taking particular medications, she would do well. (Tr. 876.) In September 2013, Ms. Michael started cardiac rehabilitation. (Tr. 815.) She began walking 20-30 minutes daily and using light free weights to perform resistance exercises. (Id.) In January 2014, Ms. Michael reported she was feeling better and her condition was improving. (Tr. 810.)

         Ms. Michael's disability applications were initially denied on November 19, 2012 (Tr. 75) and on January 4, 2013, she sought a hearing to contest the denials. (Tr. 82.) On June 27, 2014, the ALJ conducted a hearing via telephone considering Ms. Michael's disability applications. (Tr. 38-54.) At this hearing, the ALJ heard testimony from Ms. Michael and Sheryl Bustin, an impartial vocational expert. (Id.) Ms. Michael testified that she suffered from pain due to her lung nodules and pulmonary condition. (Tr. 41-42.) She testified that she has back pain everyday as well, and although she takes medication for it, the pain is still there. (Tr. 42.) Ms. Michael reported that since she quit smoking cigarettes, she has had no improvement with her pulmonary condition. (Id.) She testified that when she walks, she frequently gets dizzy and she believes it stems from the medication she is prescribed. (Tr. 44.) Ms. Michael testified she could not return to her previous position because she is too absent-minded, cannot remember very well, cannot stay focused, and cannot sit or stand for a long period of time. (Tr. 47.) She reported she could not walk for more than one block without getting out of breath and could not lift anything over ten pounds without a strain on her chest. (Tr. 48.)

         The ALJ also received and reviewed a plethora of medical records from multiple medical sources (Tr. 257-996), and had the benefit of two opinions from treating physician Dr. Murudkar[4] (Tr. 574-575; 994-996), and two opinions from non-examining state agency physician Dr. Tran.[5] (Tr. 54-67.) These medical source opinions reached markedly different conclusions regarding Ms. Michael's capacity to perform work. Dr. Murudkar completed a two-page check block residual functional capacity questionnaire in February 2013.[6] (Tr. 574-575.) Dr. Murudkar concluded that Ms. Michael's impairments were severe enough that they would constantly interfere with her attention and concentration to perform work related tasks. (Tr. 575.) Dr. Murudkar determined Ms. Michael would need to recline or lie down during an eight-hour workday in excess of the typical permitted breaks, could only walk one city block without rest or significant pain, could sit for 15 minutes and stand/walk for ten minutes, could sit for four hours and stand/walk for two hours out of an eight-hour work day and could occasionally life more less than ten pounds but never anything heavier. (Tr. 574-575.) Dr. Murudkar further stated that as a result of Ms. Michael's impairments, she would be absent from work more than four times per month. (Tr. 575.) Ultimately, Dr. Murudkar opined that Ms. Michael was not physically capable of working an eight-hour work day five days per week. (Id.)

         In contrast, Dr. Tran, the non-examining state agency physician, reviewed the medical evidence of record as of November 2012, and concluded that Ms. Michael was physically capable of lifting and carrying twenty pounds occasionally and ten pounds frequently; sitting for six hours in an eight-hour workday; and standing and walking for six hours in an eight-hour workday. (Tr. 58-59.) Thus, Dr. Tran opined that although Ms. Michael did have some limitations in the performance of certain work activities, those limitations would not prevent her from performing her past relevant work. (Tr. 60.)

         Following the hearing, on July 24, 2014, the ALJ issued a decision denying Ms. Michael's applications for disability benefits. (Tr. 22-30.) In this decision, the ALJ first found that Ms. Michael met the insured requirements of the Act through March 31, 2017. (Tr. 24.) At Step 2 of the five-step sequential analysis process that applies to Social Security disability claims, the ALJ concluded that Ms. Michael experienced the following severe impairments: diabetes, coronary artery disease, hypertension, anemia, and nodular lung disease. (Id.) At Step 3 of this sequential analysis, the ALJ concluded that none of Ms. Michael's impairments met a listing that would define her as per se disabled. (Tr. 19-20.)

         Before considering Step 4, the ALJ fashioned Ms. Michael's residual functional capacity. The ALJ concluded that Ms. Michael could perform a range of light work with limitations. (Tr. 26.) Specifically, the ALJ noted that Ms. Michael can only occasionally climb, balance, stoop, kneel, crouch, and crawl. (Id.) Further, the ALJ added the limitation that Ms. Michael should avoid concentrated exposure to pulmonary irritants such as smoke, dusts, gases, fumes, high humidity, and temperature extremes and she should perform work that can be done either sitting or standing. (Id.)

         In reaching this conclusion, the ALJ partially discounted Ms. Michael's statements concerning the intensity, persistence, and limiting effects of her symptoms, noting that many of her allegations are not documented in the evidence of record. (Tr. 26-29.) The ALJ then carefully canvassed the clinical, diagnostic, and medical opinion evidence before concluding that Ms. Michael retained the residual functional capacity to perform a range of light work. (Id.) The ALJ noted that because Ms. Michael developed coronary artery disease after the state agency medical opinions were rendered, certain limitations were necessary to accommodate her medical condition. (Tr. 29.) The ALJ added environmental restrictions due to her pulmonary history. (Id.) In addition, the ALJ added postural limitations in order to permit Ms. Michael to alternate between sitting and standing. (Id.) The ALJ explained that a sit/stand option was necessary because although Ms. Michael's coronary issues are stable, activities such as frequent climbing or crawling would be more physically demanding than work where she primarily stands all day. (Id.) Having made these findings, the ALJ concluded, consistent with the testimony of the vocational expert that Ms. Michael could return to her past relevant work, as none of her impairments precluded her from performing those positions actually and generally. (Tr. 30.) The ALJ did not reach analysis at Step 5, as he determined Ms. Michael was not disabled.

         Having exhausted her administrative remedies with respect to this adverse decision, Ms. Michael filed the instant appeal. (Doc. 1.) On appeal, Ms. Michael argues that the ALJ erred in according inadequate weight to the opinion of her treating physician. (Doc. 15 p. 8.) She then contends that, in turn, because the ALJ failed to adopt her treating physician's opinion, the Step 5 determination is unsupported by substantial evidence. (Doc. 15 p. 14.) This case is fully briefed and is now ripe for resolution.

         III. Discussion

         A. Substantial Evidence Review - the Role of this Court

         When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012). Substantial evidence “does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be “something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). “In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole.” Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D.Pa. 2003). The question before this Court, therefore, is not whether Ms. Michael is disabled, but whether the Commissioner's finding that she is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D.Pa. Mar. 11, 2014)(“[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence.”)(alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D.Pa. 1981)(“The Secretary's determination as to the status of a claim requires the correct application of the law to the facts.”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990)(noting that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary review of all legal issues . . . .”).

         B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ

         To receive benefits under the Social Security Act by reason of disability, a claimant must demonstrate an inability to “engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this requirement, a claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C. §1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under Title II of the Social ...

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