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Fisher v. Berryhill

United States District Court, S.D. Alabama, Southern Division

September 18, 2017

LARA B. FISHER, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          P. BRADLEY MURRAY, UNITED STATES MAGISTRATE JUDGE

         Plaintiff brings this action, pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security denying her claim for a period of disability and disability insurance benefits. The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 26 (“In accordance with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, . . . order the entry of a final judgment, and conduct all post-judgment proceedings.”); see also Doc. 28 (endorsed order of reference)). Upon consideration of the administrative record, plaintiff's brief, the Commissioner's brief, and the arguments of counsel at the September 14, 2017 hearing before the Court, it is determined that the Commissioner's decision denying benefits should be affirmed.[1]

         I. Procedural Background

         Plaintiff Fisher filed an application for a period of disability and disability insurance benefits on September 18, 2013, alleging disability beginning on April 30, 2006. (See Tr. 70-71.) Fisher's claim was initially denied on December 10, 2013 (Tr. 34-39) and, following Plaintiff's request for a hearing before an Administrative Law Judge (“ALJ”) (see Tr. 41-42), a hearing was conducted before an ALJ on March 12, 2015 (Tr. 441-63). On June 26, 2015, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to disability insurance benefits. (Tr. 15-25.) More specifically, the ALJ concluded that through the date last insured, December 31, 2009, Plaintiff retained the residual functional capacity to perform a reduced range of light work and, further, that in light of her residual functional capacity, she was capable of performing those light jobs identified by the vocational expert (“VE”) during the course of the administrative hearing. (See Id. at 19-25; compare Id. with Tr. 459-61 (vocational expert's hearing testimony that based on the hypothetical posed, consistent with the ALJ's ultimate RFC determination, the claimant would be capable of performing work as a mail clerk, information clerk, and office helper)). The Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council and, on October 12, 2016, the Appeals Council denied Fisher's request for review. (Tr. 6-9.) Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due to ankylosing spondylitis, fibromyalgia, history of uveitis, major depressive disorder, and generalized anxiety disorder. The Administrative Law Judge (ALJ) made the following relevant findings:

1. The claimant last met the insured status requirements of the Social Security Act on December 31, 2009.
2. The claimant did not engage in substantial gainful activity during the period from her alleged onset date of April 30, 2006 through her date last insured of December 31, 2009 (20 CFR 404.1571 et seq.).
3. Through the date last insured, the claimant had the following severe impairments: ankylosing spondylitis; fibromyalgia; history of uveitis; major depressive disorder; [and] generalized anxiety disorder (20 CFR 404.1520(c)).
. . .
4. Through the date last insured, the claimant 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 CFR 404.1520(d), 404.1525 and 404.1526).
. . .
5. After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity to perform a reduced range of light work as defined in 20 CFR 404.1567(b). That is, the claimant is able to lift and carry 10 pounds frequently and 20 pounds occasionally; sit, stand and walk for 6 hours each during an 8 hour workday; frequently use the upper and lower extremities to push and pull; frequently balance, stoop, kneel, crouch, crawl and climb ramps and stairs; no climbing of ladders, ropes or scaffolds; frequently reach, handle, finger, and feel; no exposure to extreme heat or cold; no work around unprotected heights or dangerous machinery; limited near and far visual acuity based on history of uveitis resulting in work limitations only of no driving of automotive equipment or automobile but would be able to navigate ordinary hazards in the workplace such as boxes in the hallway; able to perform simple routine tasks involving no more than simple, short instructions; and able to sustain concentration and attention for 2 hour periods.
In making this finding, the undersigned has considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529 and SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 and SSRs 96-2p, 96-5p, 96-6p and 06-3p.
In considering the claimant's symptoms, the undersigned must follow a two-step process in which it must first be determined whether there is an underlying medically determinable physical or mental impairment(s)-i.e., an impairment(s) that can be shown by medically acceptable clinical and laboratory diagnostic techniques-that could reasonably be expected to produce the claimant's pain or other symptoms.
Second, once an underlying physical or mental impairment(s) that could reasonably be expected to produce the claimant's pain or other symptoms has been shown, the undersigned must evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's functioning. For this purpose, whenever statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence, the undersigned must make a finding on the credibility of the statements based on a consideration of the entire case record.
The claimant, at the time of her alleged onset date, was 29 years of age. Currently, the claimant is 38 years old. The claimant has past work experience as an administrative assistan[t]. The claimant stated that her medical problems started after her first child was born. The claimant testified that she has fibromyalgia and eye infections. Additionally, the claimant complained of depression and anxiety. The claimant stated that she has a driver's license and does not have any driving restrictions. Through December 2009, the claimant sought treatment with South Alabama Medical, and at the hearing, the claimant reported seeking treatment 1-2 times a month, but this is not reflected in the records. She reported having chronic fatigue and sleep issues through the date last insured of December 31, 2009.
Before proceeding further, it should be noted that some of the exhibits in the record are after the date last insured of December 31, 2009. These exhibits include 5F, 7F, 8F, 9F, 10F, 11F, 12F, 13F, 15F, 16F, 17F, 18F, 19F, 20F and 21F.
From April 30, 2006 until December 31, 2009, the longitudinal medical evidence of record does not support the degree of impairment alleged or the presence of disabling mental or physical impairments. The claimant was treated through the South Alabama Medical Clinic in February 2008, the notes indicate she was a stay at home mother with two children. In April 2008, the claimant presented with complaints of depression and anxiety, and she reported experiencing panic attacks 2-3 times a week. However, the claimant was not seeking mental health treatment, and she had no history of mental health hospitalization. In May 2008, she presented with complaints of joint pain, anxiety and depression. The examination findings indicated that the claimant's appearance and affect were much better. Thereafter, in August 2008, the claimant reported hurting all over with tender points noted on examination. She also reported experiencing anxiety. She was diagnosed with ankylosing spondylosis and fibromyalgia.
ANA lab testing on April 21, 2008 was negative. Likewise, on May 21, 2008, testing for rheumatoid arthritis was negative. The sedimentation rate was within normal ranges at 5. It was noted that the claimant's c-reactive protein was outside of normal ranges at 0.04 but RPR qualitative was non-reactive.
The claimant also sought treatment from E. Franklin Rawlings, MD in April 2008. Dr. Rawlings notes indicate a diagnosis of chronic uveitis. However, these notes also reflect improvement (referenced as significant) with treatment. The undersigned has considered the claimant's diagnosed eye inflammation in the residual functional capacity, and it is noted that for the relevant period the claimant is precluded from driving automotive equipment but would be able to navigate ordinary hazards in the workplace such as boxes in the hallway.
In July 2008, the claimant was examined by John Huntwork, M.D. in an office visit. Dr. Huntwork stated that the claimant complained of fatigue, anxiety, blurred vision and chronic diarrhea. It is noted that this reference to complaints of chronic diarrhea is inconsistent with reports in Exhibit 6F wherein the claimant denied having diarrhea symptoms. Nevertheless, Dr. Huntwork noted on examination that the claimant exhibited a full range of motion in all extremities. He diagnosed the claimant with ankylosing spondylitis, refractory uveitis, fibromyalgia and IBS. He further reported in his notes that the claimant was unable to function in the workplace and would require a flexible schedule. He noted that the claimant was unable to maintain concentration because of pain and would have frequent absenteeism. The undersigned has given this opinion no weight because it is not consistent with objective testing including negative ANA results and x-ray findings, and it is not consistent with the claimant's reported activities during this period including caring for her children and performing all household chores.
The claimant also underwent a psychological consultative evaluation with Lucile Williams, Psy.D. on August 19, 2008. Dr. Williams noted that the claimant had no history of psychiatric treatment or hospitalization. With regard to her daily activities, the claimant reported she was able to take care of her children, cook, wash clothes, watch television, read and shop in stores. Dr. Williams' diagnostic impression included major depressive disorder, recurrent, and the undersigned has considered the opinion from Dr. Williams in the residual functional capacity above with regard to the mental non-exertional limitations.
On September 12, 2008, the claimant was examined by Henrietta Kovacs, M.D. in a physical consultative examination. The claimant presented with complaints of joint pains in her wrists, knees, feet, shoulders and low back pain. On exam, Dr. Kovacs noted that the claimant's range of motion was, in general, good in all joints with some limited range of motion noted in the dorsolumbar spine regarding extension. However, there was normal muscle tone, and the claimant was able to heel/toe walk and squat without complaints of pain. Dr. Kovacs' diagnostic impression included a history of recurrent uveitis, ankylosing spondylitis, fibromyalgia, anxiety, depression, headache complaints and diarrhea complaints. Dr. Kovacs did not assign any limitations to the claimant. The undersigned has given the examination findings by Dr. Kovacs, which are within the relevant period, greater weight in support [of] the residual functional capacity above.
On September 22, 2008, Dr. Huntwork completed and signed a medical status letter. He noted that the claimant was in the “horrendous situation of having young children to take care of but having varied physical complaints.” The claimant reported musculoskeletal pain in her knees, but examination findings by Dr. Huntwork were normal. The examination documented full range of motion with no redness in either eye from inflammation secondary to uveitis. The claimant exhibited a full range of [motion in the] peripheral joints with some tenderness noted that was characteristic of fibromyalgia. The claimant's lab findings, however, were positive for HLA-B27, but the sedimentation rate (a blood test to reveal inflammatory activity in the body) was normal. Dr. Huntwork treated the claimant with only a low dose of steroids despite his report that the claimant would require a flexible schedule and would experience absenteeism. Indeed, Dr. Huntwork opined that the claimant was disabled.
The undersigned assigns no weight to the opinion from Dr. Huntwork in Exhibit 14F because his opinion is not consistent with the examination findings from Exhibits 2F or 14F. Moreover, the claimant had normal x-rays and lab reports in Exhibits 6F and 22F and a normal examination in Exhibit 4F. Moreover, Dr. Huntwork's opinions are undermined by the claimant's reported activities of daily living noted by the consultative examiner in Exhibit 3F. According to the report in Exhibit [3]F, the claimant, in August 2008, stated that her daily activities included caring for her children, cooking, washing clothes, watching television, reading and shopping in stores. Moreover, the consultative examiner reported that the claimant had stopped working when she got married, and after having a baby, [because] her husband did not want her to work. Given these inconsistencies in both the notes from Dr. Huntwork regarding examination findings, the acknowledged activities of daily living in the consultative report and the other examination findings in Exhibits 4F, 6F and 22F, no weight is assigned to the opinions offered by Dr. Huntwork in Exhibits 2F and 14F. As an aside, it is also noted that the claimant stated at the hearing she had only been treated by Dr. Huntwork for a brief period with no further treatment thereafter because of a lack of funds. However, the record documents other medical treatment during the relevant period, including consultative examinations.
The claimant was treated at the Mostellar [C]linic in May 2009, and x-rays of the lumbar spine were normal. At a return visit, trigger points were noted on exam. In September 2009, the claimant denied having any symptoms of diarrhea but trigger points were again noted. She was diagnosed with fibromyalgia, back pain and uveitis. It is also noted that these records reflect that the claimant was characterized as having no lumbar abnormality with no sacroiliac joint abnormality demonstrated.
The medical evidence for the relevant time period of April 30, 2006 until December 31, 2009, fails to establish the level of restricted functioning the claimant has alleged. The claimant's allegations for this period regarding her limitations are not supported by the medical evidence or her acknowledged activities of daily living. The medical evidence documents diagnoses of fibromyalgia, ankylosing spondylitis, uveitis, major depressive disorder and anxiety; however, these records also document essentially normal examination findings as well as essentially normal lab results and x-ray findings. Moreover, the claimant's daily activities[, ] including caring for her children, performing all household chores, driving, shopping and taking care of her personal needs[, ] also undermine the credibility of her functional limitations as alleged for the relevant period. The claimant also reported no side effects from medications during this period.
In sum, the above residual functional capacity assessment is supported by a preponderance of the most credible evidence of record, including the claimant's activities of daily living, the objective medical evidence including diagnostic tests such as blood tests and x-rays, and the examination findings of Dr. Kovacs in Exhibit 4F. The medical evidence does not support the claimant's allegations of totally incapacitating symptomatology from April 30, 2006 until December 31, 2009. Likewise, the undersigned has considered the opinion of Dr. Williams in Exhibit 3F in arriving at the mental non-exertional limitations outlined above.
. . .
6. Through the date last insured, the claimant was unable to perform any past relevant work (20 CFR ...

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