Liepke-Steacy v. Commissioner of Social Security

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF NEW YORK

________________________________________

Lindsey L.-S.,

Plaintiff,

v. 6:18-CV-572

(TJM)

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

_________________________________________

THOMAS J. McAVOY,

Sr. U. S. District Judge

DECISION & ORDER

Plaintiff Lindsey L.-S. brings this action pursuant to the Social Security Act, 42

U.S.C. § 405(g), for review of a final determination by the Commissioner of Social Security

denying her application for benefits. Plaintiff alleges that the Administrative Law Judge’s

decision denying her application for benefits was not supported by substantial evidence

and was contrary to the applicable legal standards. Pursuant to Northern District of New

York General Order No. 8, the Court proceeds as if both parties had accompanied their

briefs with a motion for judgment on the pleadings.

I. PROCEDURAL HISTORY

On April 22, 2015, Plaintiff applied for Supplemental Security Income (“SSI”)

benefits through the Social Security Administration. She alleged a disability beginning April

29, 2011. The Administration initially denied Plaintiff’s application on August 24, 2015.

Thereafter, Plaintiff filed a written request for hearing on September 21, 2015.

Administrative Law Judge (“ALJ”) Kenneth Theurer held a video-conference hearing on

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September 20, 2017. ALJ Theurer on November 7, 2017 found that Plaintiff was not

disabled from her application date through the date of the decision. Plaintiff appealed this

determination to the Appeals Council of the Social Security Administration. The Appeals

Council denied Plaintiff’s request for review on April 23, 2018. Plaintiff made a timely

application to US District Court. This Court has jurisdiction over the ALJ’s decision

pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).

II. FACTS

The Court will assume familiarity with the facts and set forth only those facts

relevant to the Court’s decision.

Plaintiff alleges disability due to: bipolar disorder; anxiety; depression; degenerative

disc disease and herniated discs in her back; asthma; chronic obstructive pulmonary

disease; Klippel-Feil Syndrome1; carpal tunnel syndrome; an atrial septal defect; and a

slight tear in her right shoulder. Social Security Administrative Record (“R.”), dkt. # 8, at

1The National Institutes of Health explain that:

Klippel Feil syndrome (KFS) is a congenital, musculoskeletal condition

characterized by the fusion of at least two vertebrae of the neck. Common

symptoms include a short neck, low hairline at the back of the head, and restricted

mobility of the upper spine. This syndrome can cause chronic headaches as well as

pain in both the neck and the back. Other features may involve various other body

parts or systems. Sometimes, KFS occurs as a feature of another disorder or

syndrome, such as Wildervanck syndrome or hemifacial microsomia. In these

cases, people have the features of both KFS and the additional disorder. KFS may

be caused by mutations in the GDF6 or GDF3 gene and inherited in an autosomal

dominant manner; or, it may be caused by mutations in the MEOX1 gene and

inherited in an autosomal recessive manner. Treatment is symptomatic and may

include medications, surgery, and/or physical therapy.

https://rarediseases.info.nih.gov/diseases/10280/klippel-feil-syndrome. Reviewed on

9/13/19.

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34-35.

III. THE ADMINISTRATIVE LAW JUDGE’S DECISION

The question before the ALJ was wether Plaintiff was disabled under Section

1615(a)(3)(A) of the Social Security Act. The ALJ engaged in the five-step analysis

required by 20 C.F.R. § 416.920(a) to determine whether a claimant qualifies for disability

benefits. See R. at 34-48.

The Social Security Administration regulations outline the five-step,

sequential evaluation process used to determine whether a claimant is

disabled: (1) whether the claimant is currently engaged in substantial gainful

activity; (2) whether the claimant has a severe impairment or combination of

impairments; (3) whether the impairment meets or equals the severity of the

specified impairments in the Listing of Impairments; (4) based on a “residual

functional capacity” assessment, whether the claimant can perform any of his

or her past relevant work despite the impairment; and (5) whether there are

significant numbers of jobs in the national economy that the claimant can

perform given the claimant's residual functional capacity, age, education, and

work experience.

McIntyre v. Colvin, 758 F.3d 146, 150 (2d Cir. 2014).

The ALJ applied these five steps. At Step 1, the ALJ found that Plaintiff had not

engaged in substantial gainful activity since April 22, 2015, the application date. Id. at 36.

The ALJ considered Plaintiff’s posted earnings and new-hire wage information together

with the evidence as a whole. Id. At Step 2, the ALJ found that Plaintiff suffered from the

severe impairments of degenerative disc disease of the cervical spine and lumbar spine,

mild carpal tunnel syndrome, headaches, shoulder impairment, bipolar disorder,

depressive disorder, and anxiety. Id. At Step 3, the ALJ concluded that Plaintiff did not

have an impairment or combination of impairments that met or medically exceeded the

severity of a listed impairment in 20 C.F.R. 416.920(d), 416.925, and 416.926. Id. at 37.

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At step four, the ALJ held that Plaintiff had the residual functional capacity to

perform less than the full range of sedentary work as defined in 20 CFR 416.967(a). Id. at

39-40. Plaintiff could lift and/or carry ten pounds occasionally, sit for six hours, and stand

and/or walk for two hours in an eight-hour day with normal breaks. Id. at 39. She could

occasionally climb ramps or stairs, balance, stoop, kneel, crouch, and crawl. Id. She

needed to alternate between sitting and standing two times per hour for no more than five

minutes while remaining on task. Id. She retained the ability to understand and follow

simple instructions and directions, perform simple tasks with intermittent supervision and

independently, maintain attention and concentration for simple tasks, regularly attend to a

routine and maintain a schedule, and relate to and interact with other coworkers to the

extent necessary to carry out simple tasks. Id. at 39-40. She is able to complete simple

tasks without the need for frequent supervision and can interact with supervisors on an

intermittent basis throughout the workday and can handle reasonable levels of work-related

stress in that she can make simple decisions directly related to the completion of her tasks

in a stable, unchanging work environment. Id. at 40. The ALJ used a two-step process to

make this determination. First, the ALJ considered whether an underlaying medically

determinable physical or mental impairment could reasonably be expected produce the

Plaintiff's symptoms. Id. Next, the ALJ evaluated the intensity, persistence, or functionally

limiting effects of the symptoms. Id. This evaluation came from a consideration of all

symptoms and the extent to which these symptoms can reasonably be accepted as

consistent with the objective medical evidence and other evidence. Id.

The ALJ also found that the claimant’s medically determinable impairments could

reasonably be expected to cause the alleged symptoms; however, the claimant’s

statements concerning the intensity, persistence and limiting effects of these symptoms are

not entirely consistent with the medical evidence and other evidence in the record. Id. at

40. Among other items, the ALJ considered the MRI of Plaintiff's cervical spine performed

in May 2014, January 2016 and January 2017, the MRI of Plaintiff's lumbar spine

performed in July 2010 and August 2015, Plaintiff's treatment notes and medical reports,

the MRI of Plaintiff's brain performed in January 2016, the MRI of Plaintiff's right shoulder

performed in May 2015, Plaintiff's clinical findings during neurological examination,

Plaintiff's pulmonary function test performed in September 2015, Plaintiff's clinical findings

during the consultative examination in August 2015, Plaintiff's mental status exam in May

2015, Plaintiff's reports on her daily activities, and the opinion of consultative examiner

Elke Lorensen, MD, an opinion the ALJ gave great weight. Id. at 44. The ALJ also gave

great weight to the opinion of State Agency psychological consultant Vigita Reddy, PhD.

Id. at 46. Conversely, the ALJ afforded little weight to the testimony of Plaintiff's treating

physician, Nathaniel Gould, MD and her nurse, David Campola, NP, who was not a

medical professional. Id. at 45. The ALJ also assigned little evidentiary weight to the

medical opinions of Plaintiff's treating psychologist David Stang, PhD. Id. at 45-46. The

ALJ found this opinion was not supported by the evidence of the record. Id. at 45-46. “In

sum, the above residual functional capacity assessment is supported by the diagnostic

images, the clinical findings during mental status exams and physical exams, Dr.

Lorensen’s opinion, and Dr. Reddy’s opinion.” Id. at 47.

Finally, the ALJ addressed the step-five determination of Plaintiff's ability to work

considering her residual functional capacity, age, education, and work experience. Id. at

48. The ALJ employed the Medical-Vocational guidelines of 20 C.F.R. Part 404, Subpart

P, Appendix 2 (2015). Id. Determining that testimony of the vocational expert was

consistent to the evidence of record, the ALJ concluded there were ample jobs available

which Plaintiff could perform. Id. Based upon this five-step evaluation, the ALJ found that

Plaintiff was not disabled. Id. at 49.

IV. STANDARD OF REVIEW

The Court's review of the Commissioner's determination is limited to two inquiries.

See 42 U.S.C. § 405(g). First, the Court determines whether the Commissioner applied

the correct legal standard. See Tejada v. Apfel, 167 F.3d 770, 773 (2d Cir. 1999); Balsamo

v. Chater, 142 F.3d 75, 79 (2d Cir. 1998); Cruz v. Sullivan, 912 F.2d 8, 11 (2d Cir. 1990);

Shane v. Chater, No. 96-CV-66, 1997 WL 426203, at *4 (N.D.N.Y July 16, 1997)(Pooler,

J.)(citing Johnson v. Bowen, 817 F.2d 983, 986 (2d Cir. 1987)). Second, the Court must

determine whether the Commissioner's findings are supported by substantial evidence in

the administrative record. See Tejada, 167 F.3d at 773; Balsamo, 142 F.3d at 79; Cruz,

912 F.2d at 11; Rutherford v. Schweiker, 685 F.2d 60, 62 (2d Cir. 1982). A

Commissioner's finding will be deemed conclusive if supported by substantial evidence.

See 42 U.S.C. § 405(g); see also Perez, 77 F.3d at 46; Townley v. Heckler, 748 F.2d 109,

112 (2d Cir. 1984)("It is not the function of a reviewing court to determine de novo whether

a Plaintiff is disabled. The [Commissioner's] findings of fact, if supported by substantial

evidence, are binding.")(citations omitted).

In the context of Social Security cases, substantial evidence consists of "more than

a mere scintilla" and is measured by "such relevant evidence as a reasonable mind might

accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401,

91 S. Ct. 1420, 1427, 28 L. Ed.2d 842 (1971)(quoting Consolidated Edison Co. v. NLRB,

305 U.S. 197, 229, 59 S. Ct. 206, 217, 83 L. Ed. 126 (1938)). Where the record supports

disparate findings and provides adequate support for both the Plaintiff's and the

Commissioner's positions, a reviewing court must accept the ALJ's factual determinations.

See Quinones v. Chater, 117 F.3d 29, 36 (2d Cir. 1997)(citing Schauer v. Schweiker, 675

F.2d 55, 57 (2d Cir. 1982)); Alston v. Sullivan, 904 F.2d 122, 126 (2d Cir. 1990). Although

the reviewing court must give deference to the Commissioner’s decision, a reviewing court

must bear in mind that the Act is ultimately “‘a remedial statute which must be ‘liberally

applied;’ its intent is inclusion rather than exclusion.’” Vargas v. Sullivan, 898 F.2d 293, 296

(2d Cir. 1990)(quoting Rivera v. Schweiker, 717 F.2d 719, 723 (2d Cir. 1983)).

V. ANALYSIS

Plaintiff alleges two sets of errors in the ALJ’s opinion, which the Court will address

in turn.

A. Weight given to different medical opinions

Plaintiff first argues that the ALJ erred in assigning little evidentiary weight to the

opinions of her treating physician, Dr. Nathaniel Gould, MD, NP David Compola, and her

treating psychologist, David Stang, PhD. She also contends that the ALJ erred by giving

great weight to the opinion of an consultative physician, Dr. Elke Lorensen, and a

consultative psychologist, Vigita Reddy, PhD. Plaintiff argues that the ALJ improperly

discounted the opinions of her treating physicians and psychologist in favor of the

consultative examiners.

Normally, an ALJ is required to find a treating physician’s opinion controlling when

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the opinion is “well-supported by medically acceptable clinical and laboratory diagnostic

techniques and is not inconsistent with the other substantial evidence in your case record.”

20 C.F.R. 404.1527(c)(2). “On the other hand, in situations where ‘the treating physician

issued opinions that [were] not consistent with other substantial evidence in the record,

such as the opinion of other medical experts,’ the treating physician's opinion ‘is not

afforded controlling weight.” Pena ex rel. E.R. v. Astrue, 2013 WL 1210932, at *15

(E.D.N.Y. March 25, 2013) (quoting Halloran v. Barnhart, 362 F.3d 28, 32 (2d Cir. 2004));

Snell v. Apfel, 177 F.3d 128, 133 (2d Cir.1999) (“When other substantial evidence in the

record conflicts with the treating physician's opinion . . . that opinion will not be deemed

controlling. And the less consistent that opinion is with the record as a whole, the less

weight it will be given.”). “Failure to provide ‘good reasons’ for not crediting the opinion of a

claimant’s treating physician is a ground for remand.” Snell, 177 F.3d at 133. “[T]o

override the opinion of the treating physician, we have held that the ALJ must consider,

inter alia: (1) the frequen[cly, length, nature, and extent of treatment; (2) the amount of

medical evidence supporting the opinion; (3) the consistency of the opinion with the

remaining medical evidence; and, (4) whether the physician is a specialist.” Greek v.

Colvin, 802 F.3d 370, 375 (2d Cir. 2015) (quoting Selian v. Astrue, 708 F.3d 409, 418 (2d

Cir. 2013)). An ALJ must “set forth her reasons for the weight she assigns to the treating

physician’s opinion.” Shaw v. Chater, 221 F.3d 126, 134 (2d Cir. 2000).

i. Dr. Gould

Plaintiff objects to the limited evidentiary weight the ALJ provided to Dr. Gould’s

opinion that should could “lift five pounds, stand or walk for 30 minutes at a time for a total

of three hours in an eight-hour day, and sit for 20 minutes at a time for a total of three

hours in an eight-hour day.” R. at 45. In addition, Dr. Gould found that Plaitniff would have

“to lie down intermittently throughout the day,” and could only “occasionally climb, balance,

kneel, crouch, crawl, and stoop[.]” Id. She also suffered from “mild limitations in reaching,

handling, fingering, and feeling” and “would be of[f] task at least 25% of the time and would

be absent more than four days per month.” In explaining the weight he provided to Dr.

Gould’s opinion, the ALJ concluded that “it is not supported by the objective medical

evidence, including the diagnostic images or the clinical findings during physical

examinations.” Id. “Moreover,” the ALJ found, “this opinion is inconsistent with other

opinion evidence of record, including Dr. Lorensen’s examining source opinion.” Id.

The ALJ’s opinion reviewed the diagnostic images documenting Plaintiff's issues

with her cervical and lumbar spine. Id. at 40-41. The ALJ also noted Plaintiff's complaints

of pain over a period of several years, the results of medical examinations related to that

pain, and the results of medical examinations testing her movement and flexibility. Id. at

40-41. The ALJ also pointed to a number of examinations where the Plaintiff displayed

normal “gait and station,” “normal muscle strength and tone,” “full range of motion of her

shoulders, elbows, wrists, or fingers bilaterally,” and “no strength deficits in her upper

extremities[.]” Id. at 41. Those medical findings, the ALJ concluded, “suggest that the

claimant has no significant limitations for standing, walking, or using her upper extremities.”

Id. Likewise, another examination in January 2017 found Plaintiff “gait and stance were

normal and she had no strength deficits,” findings that “suggest that the [plaintiff] has no

significant functional limitations.” Id. The ALJ also pointed out that Dr. Lorensen’s August

2015 examination of Pliantiff did “not support the [plaintiff's] allegations regarding the

severity of her conditions,” and described the findings of that examination. Id. at 42.

The Court finds that the ALJ had substantial evidence for the weight he afforded Dr.

Gould’s opinions. The ALJ pointed to medical evidence in the record that indicated that Dr.

Gould overstated Plaintiff's limitations, noting that the history of Plaintiff's limitations

demonstrated that she had more flexibility, strength, range of motion, and ability to walk

without limitation than Dr. Gould indicated. The ALJ also pointed to Dr. Lorensen’s

physical examination in finding that the record supported fewer limitations than Dr. Gould

suggested. The ALJ provided a sufficient explanation for the weight provided Dr. Gould’s

position, and the Plaintiff's motion will be denied in this respect.

ii. Campola

The ALJ also granted “little evidentiary weight” to the opinion of David Campola, NP,

who treated Plaintiff for pain management. R. at 45. Campola had concluded that Plaintiff

could “lift five pounds or less, stand and/or walk for ten minutes at a time for a total of one

hour or less in an eight-hour day, and sit for 30 minutes at a time for a total of one hour or

less in an eight-hour day.” Id. The ALJ found that Campola “suggests that the [Plaintiff] is

only able to stand, walk, and sit for a combined total of two hours in an eight-hour period,

which implies that she is essentially bed-ridden.” Id. For Campola, Plaintiff could “never . .

. climb, balance, kneel, crouch, crawl, or stoop.” Id. Her limitations in “reaching, handling,

and fingering” were “severe.” Id. Because of Plaintiff's pain, fatigue, and inability to

concentrate, she would ‘be off task at least 50% of the time.” Id. She would need to miss

four days a month. Id. As with Gould’s opinion, the ALJ found that Campola’s limitations

were “not supported by the objective medical evidence, including the diagnostic images or

the clinical findings during physical examinations.” Id. Other opinion evidence also

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contradicted Campola’s findings.” Id.

The Defendant argues that Campola is not a treating physician as defined by social

security regulations and is therefore not entitled to the same level of deference as a

treating physician. The Social Security regulations in place at the time Plaintiff filed her

claim gave “controlling weight” to the opinion of a treating physician if that physician’s

opinion was “well-supported by medically acceptable clinical and laboratory diagnostic

techniques and is not inconsistent with other substantial evidence in [the] case record[.]”

20 C.F.R. § 416.927. Those regulations, however, excluded a nurse practitioner from the

definition of “acceptable medical source.” 20 C.F.R. § 404.1502 (a)(7). Under those

circumstances, Campola’s opinion “can be considered when determining the severity of the

claimant’s impairment and ability to work but are not necessarily entitled to controlling

weight.” Fax. v. Comm’r of Soc. Sec., No. 1:14-cv-00530 (MAD), 2015 U.S. Dist. LEXIS

81592 at *8 (N.D.N.Y,. June 24, 2015). Thus, “while the ALJ is certainly free to consider

the opinions of [a nurse practitioner] in making his overall assessment of a claimant’s

impairments and residual abilities, those opinions do not demand the same deference as

those of a treating phyisician.” Genier v. Astrue, 298 Fed. Appx. 105, 108 (2d Cir. 2008).

Even using the more difficult and deferential standard afforded a treating physician,

the ALJ had substantial evidence for his decision to give only limited weight to Campola’s

opinion. As with Gould, the ALJ cited to evidence in the record that allowed for fewer

limitations on Plaintiff’s activities than Campola did. The evidence cited by the ALJ,

including Lorensen’s examination and evaluation of Plaintiff, provides substantial evidence

for finding fewer restrictions than Campola found. The ALJ explained the basis for his

opinion, and the Court finds that opinion supported by substantial evidence. The Plaintiff’s

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motion will be denied in this respect as well.

iii. Dr. Lorensen

Dr. Elke Lorensen, MD., a consultative examiner, prepared an internal medicine

examination of Plaintiff on August 17, 2015. See R. at 702-07. Lorensen reported that the

New York State Officer of Disability Determination referred Plaintiff to him for a physical

examination. Id. at 702. According to Lorensen, Plaintiff had a diagnosis of neck pain,

back pain, headaches and right shoulder pain. Id. at 705. Lorensen interviewed Plaintiff,

who complained of the pains described previously, told Lorensen of her current

medications and reported her activities of daily living. Id. at 702-03. Lorensen concluded

from the physical examination that Plaintiff had “[n]o gross limitations sitting, standing,

walking, and handling small objects with the hands. Moderate restrictions bending, lifting,

reaching, turning the head.” Id. at 705. Plaintiff complains that Dr. Lorensen did not treat

her and that his speciality is vascular surgery. She does not complain of a vascular

condition.

The ALJ read Dr. Lorensen’s opinion to be “that the claim ant has no limitations for

sitting, standing, walking, or handling small objects,” but “moderate limitations for bending,

lifting, reaching, and turning her hear.” R. at 44. The ALJ gave the opinion “great weight.”

Id. The opinion, the ALJ found, deserved such weight “because it is a medical opinion and

is supported by Dr. Lorensen’s findings upon examining the claimant.” Id. In concluding

that Dr. Lorensen’s findings were supported by the medical evidence, the ALJ pointed to

Dr. Lorensen’s findings concerning Plaintiff's gait, ability to squat, lack of assistive devices

in walking, range of motion and flexibility, ability to stand, the stability and tenderness of

her joints, range of motion, and finger dexterity. Id.

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As with his other conclusions regarding the medical opinions, the ALJ had

substantial evidence to support his conclusion that Lorensen’s opinion deserved great

weight. Plaintiff points out that Lorensen’s specialty is vascular medicine, a specialty that

does not focus on her back, neck, and other mental and physical issues. Still, Lorensen

was able to perform a medical exam and offer an opinion. The ALJ explained how

Lorensen’s opinion found support in the medical record and in his own examination, and

how that consistency explained the weight he provided to Lorensen’s opinion. The Court

will deny the Plaintiff’s motion in this respect as well.

iv. Stang

The ALJ provided little evidentiary weight to the opinion of Dr. Stang, who concluded

that Plaintiff suffered from “moderate limitations in her ability to interact with others, adapt

or manage herself, effectively function independently, consistently maintain personal

appearance, and function reliably.” Id. at 45. He also found that she had “marked

limitations in her ability to behave predictably and reasonably and appropriately deal with

stress.” Id. She also suffered from “mild limitations in her ability to understand, remember,

and apply information, use good judgment, concentrate, persist, and maintain pace.” Id. at

45-46. Dr. Stang concluded that Plaitniff would likely miss more than four days per month

and be off task from work more than 50% of the time in an eight-hour workday. Id. at 46.

He reported that Plaintiff suffered from depression and anxiety, causing her difficulty in

functioning and managing stress. Id. This condition, Stang found, also placed “marked

restrictions” on Plaintiff’s “activities of daily living and maintaining social functioning.” Id.

In limiting the weight accorded that opinion, the ALJ pointed to record evidence in

the form of “clinical findings during mental status examinations.” Id. During examinations,

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the ALJ pointed out, Plaintiff was reported to be “cooperative, but guarded”; she had

normal speech and motor activity; she had an appropriate affect; though “anxious,” she

was “alert, and fully oriented.” Id. She had normal “content and perceptions,” and could

concentrate and pay attention. Id. She was “above-average” in intelligence, had “intact”

judgment, and did not express any suicidal or homicidal ideations. Id. Beyond these initial

examinations in mid-2015, the ALJ noted, “Dr. Stang’s subsequent progress notes do not

contain clinical findings and merely recite the claimant’s subjective complaints, which

focused on marital discord, divorce, custody, and visitation issues, and problems with her

boyfriend’s children.” Id.

Here again the ALJ explained the weight he gave to Sang’s opinion by citing

evidence in the medical record that contradicted the limitations that Sang assigned Plaintiff

in his report. The ALJ had substantial evidence for the weight assigned to Sang’s report,

and the Court will deny the Plaintiff’s motion in this respect as well.

v. Reddy

The Plaintiff also contends that the ALJ provided too much weight to opinion of

Virginia Reddy, PhD, who served as a non-examining state-agency source on Plaintiff’s

mental condition. Reddy, “a State Agency psychological consultant,” reviewed Plaintiff’s

file and concluded “that the [plaintiff] has moderate limitations in her ability to interact

appropriately with the general public, accept instructions, respond appropriately to criticism

from supervisors, get along with coworkers or peers without distracting them or exhibiting

behavioral extremes, respond appropriately to changes in the work setting, and set realistic

goals or make plans independently of others.” Id. at 46. At the same time, Reddy found

that Plaintiff suffered “no limitations in her ability to understand, remember, and sustain

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concentration, ask simple questions or request assistance, maintain socially appropriate

behavior, adhere to basic standards of neatness and cleanliness, be aware of normal

hazards and take appropriate precautions, travel in unfamiliar places, or use public

transportation.” Id.

The ALJ gave “great weight” to Dr. Reddy’s opinion on Plaintiff’s mental residual

function capacity. Id. That weight, the ALJ concluded, came because Dr. Reddy offered a

“medical opinion . . . supported by the clinical findings during mental status examinations.”

Id. The ALJ pointed to mental status examinations described above, which showed that,

despite difficulties with stress, Plaintiff demonstrated the ability to concentrate and interact

with people, was of “above-average” intelligence, and did not demonstrate any suicidal or

homicidal intentions. Id. at 46. All of this evidence, the ALJ concluded, provided support in

the record for Reddy’s opinions.

As with the other opinion testimony, the Court finds that the ALJ had substantial

evidence to support his conclusions about the evidentiary weight to be assigned Reddy’s

opinions. The ALJ pointed to record evidence that supported his conclusions about that

testimony, noting that Plaintiff’s affect and appearance in mental-health examinations

demonstrated that she could function and interact with others in the workplace. The ALJ

explained the weight provided Reddy’s opinion, and had substantial evidence to do so.

The motion will be denied in this respect as well.

B. Date of Onset

As a basis for remand beyond the ALJ’s alleged failure to provide proper weight to

the opinion evidence, the Plaintiff contends that the ALJ failed to consider evidence which

might indicate that Plaintiff’s condition had worsened since she initially filed her application

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for benefits in 2015. She points to a January 5, 2016 cervical spine MRI that demonstrated

allegedly new injuries, points out that the consultative examiner did not have this

information in preparing his report, and contends that the ALJ erred by failing to consider

whether Dr. Lorensen’s report was adequate given this new information. If the ALJ had

considered a later date than April 22, 2015 as the onset date, she argues, the ALJ would

have been able to address more clearly whether Plaintiff’s condition had worsened.

In determining Plaintiff’s impairments, the ALJ noted that:

X-rays of the claimant’s cervical spine performed in August 2011 showed narrowing

at the C6 level and mild multilevel instability. An MRI of the claimant’s cervical spine

performed in May 2014 showed disc herniations at the C3-C4, C5-C6 and C6-C7

levels and congenitally fused C2-C3 vertebrae, which is consistent with Klippel-Feil

syndrome. An MRI of her cervical spine performed in January 2016 showed no

acute injury, congenital fusion of the skull base and C1 and C2/C3, with stable

basilar invagina. The MRI showed stable herniations at C3-C4, C4-C5, C5-C6, and

C6-C7, stable mild to moderate foraminal stenosis at the C3-C4, C4-C5, and C6-C7

levels, and stable, mild reversal of the cervical lordosis. An MRI performed in

January 2017 showed similar findings with no significant changes. She complains

of headaches, but neurological exam results were normal.

R. at 37. In assessing Plaintiff’s Residual Functional Capacity at Step 4 of the analysis, the

ALJ repeated these assessments of Plaintiff’s cervical spine issues, as well as his

assessment of her lumbar spine problems and other mobility issues. Id. at 40-41. The ALJ

concluded that “[t]he claimant’s neck and back impairment would be expected to cause her

some functional limitations for lifting, carrying, standing, walking, and performing postural

activities, which are acounted for in the above-defined-residual functional capacity.” Id. at

41. The ALJ also pointed to evidence showing that “the claimant’s treatment notes indicate

that her back pain resolved after an epidural steroid injection in August 2015.” Id. In

providing little weight to Dr. Gould’s and NP Campola’s opinions, the ALJ cited these

images, including those produced in 2016 and 2017, finding that their opinions were “not

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supported by the objective medical evidence, including the diagnostic images or the clinical

findings during physical examinations.” Id. at 45.

The Court finds it clear from the record that the ALJ considered the most recent

diagnostic imagery in establishing Plaintiff's RFC and in evaluating the expert reports. The

ALJ, as explained above, explicitly cited that imagery in establishing the Plaintiff's RFC.

The ALJ found that such imagery supported Dr. Lorensen’s conclusions and undermined

those of Dr. Gould and NP Campola, noting that the diagnostic imagery supported findings

of pain and limitation, but that the same imagery did not support the greater restrictions

posed by Plaintiff's experts. The ALJ also noted that Dr. Lorensen’s findings were not

based on a reading of the medical file or on a simple examination of diagnostic reports, but

on an examination of the Plaintiff. As such, the ALJ had substantial evidence, which

included the diagnostic reports from 2016 and 2017, and used that evidence, in assessing

the experts and the Plaintiffs RFC. The Court will deny the Plaintiff's motion in this respect

as well.

VI. CONCLUSION

For the foregoing reasons, Plaintiff's motion for judgment on the pleadings is

DENIED. The Commissioner's motion for judgment on the pleadings is GRANTED. The

decision of the Commissioner is affirmed.

IT IS SO ORDERED. aT

Thomas J. pe

Dated: September 13, 2019 Senior, U.S. District Judge

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