# GOREE v. COMMISSIONER OF SOCIAL SECURITY

> District Court, E.D. Pennsylvania · October 26, 2020

URL: https://www.frixlaw.com/law-library/cases/10399860

## Case

- **Court:** District Court, E.D. Pennsylvania
- **Decided:** October 26, 2020
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA

KELVIN O’NEIL GOREE, :
Plaintiff, : CIVIL ACTION
:
: NO. 19-3260
v. :
:
COMMISSIONER OF SOCIAL SECURITY, :
Defendant. :

MEMORANDUM OPINION

DAVID R. STRAWBRIDGE
UNITED STATES MAGISTRATE JUDGE October 26, 2020

This action was brought pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final
decision of the Commissioner of the Social Security Administration (the “Commissioner”), which
denied the application of Kelvin O’Neil Goree (“Goree”) for Disability Insurance Benefits (“DIB”)
under Title II of the Social Security Act, 42 U.S.C. §§ 301, et seq. Presently before the Court is
Plaintiff’s Brief and Statement of Issues in Support of Request for Review (“Pl. Br.”) (Doc. 8);
Defendant’s Response to Request for Review (“Def. Br.”) (Doc. 13); Plaintiff’s Brief in Reply to
Defendant’s Response to Plaintiff’s Request for Review (“Pl. Reply”) (Doc. 14); and the record of
the proceedings before the Administrative Law Judge (“ALJ”) (Doc. 7) (hereinafter “R.”).
Plaintiff asks the Court to vacate the Commissioner’s final administrative decision and remand for
further proceedings. The Commissioner seeks the entry of an order affirming the decision of the
ALJ that the Plaintiff was not disabled. For the reasons set forth below, we affirm.
I. FACTUAL AND PROCEDURAL HISTORY
A. Benefits application and early treatment
Goree protectively filed an application for DIB on March 16, 2016, when he was 56 years
old. He dated the onset of his alleged disability to June 1, 2015, when he stopped working as a
forklift operator in an Amazon warehouse after his physician placed lifting restrictions on him due
to his complaints of low back pain. Prior to that position, he had a long history of work as a
maintenance electrician and building maintenance worker. (R. 138, 183, 334, 342.) He again
worked as an electrician through an internship for Project HOME in 2016, after his alleged
disability onset date. Earlier in his working life, he served in the Navy for five years, where he

suffered an injury in 1983 to his ankle.
Goree contended that he was unable to work due to osteochondral lesions in his left ankle,
tinnitus, post-traumatic stress disorder, and a herniated disc in the lumbar spine. (R. 333.) During
the period of time at issue, he had lived with his daughter and at a home for veterans. He also had
periods of homelessness. Goree received comprehensive care for his various conditions, as well
as social work and housing referrals, at the VA Medical Center in Philadelphia. A board-certified
internist, Leah Jones, M.D., principally managed his care for physical impairments, and
psychiatrist Judith Navarro, M.D., saw him at the VA’s Mental Health Clinic.1
B. Adjudication of application
Based on the records before it at that time, the state agency denied Goree’s claim on August

19, 2016. Upon Goree’s request for reconsideration, and given the earnings records showing that
he had been performing work since the date he initially filed his claim, the state agency sent him

1 Goree’s mental impairments are not the focus of this appeal, although they were among the
impairments he identified as disabling. He has a history of alcohol dependence, cocaine and
marijuana abuse, and depression. In February 2018, Goree was hospitalized for suicidal and
homicidal ideation against a backdrop of life stressors and substance abuse. He was prescribed
medications for depressive symptoms and to help him sleep. MRI studies of his brain also showed
evidence of a traumatic brain injury (“TBI”). Upon discharge he displayed an improved mood.
His diagnoses were polysubstance use disorder, depressive disorder, TBI, mild cognitive
impairment and questionable post-traumatic stress disorder (“PTSD”). (R. 757-58.) He responded
positively to subsequent outpatient treatment with Dr. Navarro at the VA clinic. Treatment notes
from September 2018, closer to the time of the hearing, reflect that Goree reported low energy and
self isolation, “bad” depression, and disturbed sleep. Dr. Navarro provided therapy and counseled
against drug and alcohol use but otherwise maintained his medications. (R. 2467-70.)_
for consultative mental health and orthopedic examinations in July and August 2017. Of note here,
Goree was examined on July 27, 2017 by Juan Carlos Cornejo, D.O. Dr. Cornejo also ordered and
reviewed x-rays of the left ankle and lumbar spine, although he did not review any historical
records. Dr. Cornejo reported that Goree was able to participate in the examination without
difficulty and that findings on physical exam were largely normal. Dr. Cornejo noted tenderness

in the left ankle area but otherwise saw no signs of atrophy or any indicia that Goree relied upon
an assistive device for ambulation. Dr. Cornejo observed that Goree walked with a limp on the
left during the evaluation but that the limp was less noticeable when he was observed leaving the
office after the examination and walking without an aid to the train station, several blocks away.
To conclude the reconsideration process, Arvind Chopra, M.D., a medical doctor retained
by the state agency, reviewed the expanded record and offered his opinion about Goree’s physical
functional capacity. Based upon his opinion, and considering one also offered by a reviewing
psychiatrist, the state agency denied the claim on reconsideration on September 25, 2017. (R. 272-
82.)

Goree requested a hearing and, through counsel, submitted additional medical records of
his treatment at the VA. When asked by the ALJ at the November 20, 2018 hearing why he stopped
working, he responded that it was due to his “bad back, and everything’s messed up. I stutter. It’s
a mess.” (R. 154.) The ALJ asked Goree about the cane that he brought to the hearing. In response
to the question of when Goree acquired a cane, he answered that it was “as soon as [he] got out of
the Navy,” which was in 1983. Goree testified that despite having had ankle pain even dating back
to his time in the Navy, he was able to work as an electrician because he was young and could put
up with the pain. (R. 164.) Goree testified that even after he had to move from the place he lived
with his adult daughter, he still relied on his daughter to make appointments for him, as he tends
to forget things. (R. 158.) Referring to his daily life at the veterans’ home, Goree testified that he
lies around and watches movies on his phone. (R. 158.)
Goree’s daughter also testified at the hearing, reiterating statements she made in a Third
Party Statement in December 2016. In her statement, she had described his ADLs as watching
television, reading and playing with her children, then aged 2 and 6. (R. 389-96.) She testified at

the hearing that his physical condition worsened since then, as he was no longer able to go places
with her kids. (R. 175.) At the hearing she also corroborated Goree’s complaints of impaired
memory and limited attention span, describing it as having deteriorated since early 2017. (R. 179-
80.) She testified that she could no longer let Goree watch her children without another adult being
present. (R. 172.) She also confirmed he long had a cane but that he previously left it behind
when he went to work. She estimated that 2014 was the point in time at which Goree no longer
walked without using the cane. (R. 176.)
The ALJ issued his decision on February 22, 2019. He determined that Goree was not
disabled at any time since the June 1, 2015 alleged onset date in that, although he could not perform

any of his past relevant work, there were other jobs that existed in significant numbers in the
national economy that he could perform. (R. 139-40.) The ALJ explained, as we discuss below,
that in reaching this conclusion about Goree’s functional capacity he gave “little weight” to a
statement of Dr. Jones in which she opined that if Goree tried to work, he would frequently be
absent, he would be off task 25% of the workday, he would require opportunities to lie down
during the workday, and he would require a cane to ambulate more than 50 feet. (R. 136-38.) The
ALJ also gave little weight to aspects of the opinion of Dr. Cornejo that accompanied the report
of his consultative examination of Goree in July 2017. He gave “great weight” to certain aspects
of the opinion rendered in August 2017 by the state agency reviewing physician, Dr. Chopra. (R.
135-36, 138.) Goree sought review in the Appeals Council and submitted approximately 100
pages of records from the VA to update his condition since the November 2018 hearing. That
body, however, found no reason to set aside the ALJ’s decision, leaving it the final decision of the
Commissioner. (R. 1-6.) This litigation followed.
II. STANDARD OF REVIEW

This Court must determine whether substantial evidence supports the Commissioner’s
decision. 42 U.S.C. § 405(g); Rutherford v. Barnhart, 399 F. 3d 546, 552 (3d Cir. 2005).
Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); Reefer v. Barnhart, 326
F.3d 376, 379 (3d Cir. 2003). Substantial evidence is “more than a mere scintilla but may be
somewhat less than a preponderance of evidence.” Rutherford, 399 F.3d at 552. The factual
findings of the Commissioner must be accepted as conclusive, provided they are supported by
substantial evidence. Richardson, 402 U.S. at 390 (citing 42 U.S.C § 405(g); Rutherford, 39 F.3d
at 552). The review of legal questions presented by the Commissioner’s decision, however, is
plenary. Shaudeck v. Commissioner of Social Security Admin., 181 F.3d 429, 431 (3d Cir. 1999).

III. DECISION UNDER REVIEW
The issue before the ALJ at the time of his February 22, 2019 decision was whether Goree
had been disabled within the meaning of the Act at any time since his June 1, 2015 alleged onset
date. In making this determination, he relied upon the five-step sequential evaluation process set
forth in 20 C.F.R. § 404.1520(a). At Step One, the ALJ found that Goree had not engaged in
substantial gainful activity since the alleged onset date, except during the second quarter of 2016,
as to which the ALJ’s remaining findings would not apply. (R. 126.) At Step Two, he found that
Goree had demonstrated that he suffered from a severe, medically-determinable impairment, e.g.,
one that causes functional limitations and has more than a de minimus effect on his ability to
perform basic work activities. (R. 127.) At Step Three, the ALJ concluded that Goree did not
have an impairment or combination of impairments that satisfy the criteria of the listed
impairments in 20 C.F.R. § 404, Subpart P, Appendix 1, and therefore could not establish his
entitlement to benefits on that basis, requiring that the evaluation process continue. (R. 127-29.)
Plaintiff does not challenge these findings.

The ALJ then considered Goree’s residual functional capacity (“RFC”), which is defined
as “the most [a claimant] can do despite [his] limitations.” 20 C.F.R. § 404.1545(a)(1). The ALJ
determined:
6. After careful consideration of the entire record, the
undersigned finds that the claimant has the residual functional
capacity to perform medium work as defined in 20 CFR
404.1567(c) except he can lift and carry 50 pounds occasionally
and 25 pounds frequently, sit for six hours in an eight-hour
workday, and stand and walk for five hours in an eight-hour
workday. He can frequently push and pull with the right lower
extremity. He can occasionally climb ramps and stairs. He can
never climb ladders, ropes, or scaffolds. He can frequently
balance, stoop, kneel and crouch. He can occasionally crawl. He
can operate foot controls with the bilateral lower extremities.
He can tolerate moderate background noise, such as business
office where typewriters are used, department store, grocery
store or light traffic. The claimant can concentrate in the
workplace for two hours before requiring a break. He is limited
to performing simple, routine tasks. He can occasionally
interact with supervisors, coworkers and the general public. He
can frequently respond appropriately to changes in a routine
work setting. He is precluded from production rate pace work,
but rather goal-oriented work.
(R. 129) (bold in original). Applying this RFC and in light of the fact that Goree’s past relevant
work was skilled or semiskilled, the ALJ found at Step Four that Plaintiff was unable to perform
any past relevant work. (R. 138.) The ALJ then proceeded to Step Five to determine whether
Goree was capable of performing any other jobs that exist in significant numbers in the national
economy. This analysis took into account that Goree was in the “advanced age” category as of his
alleged disability onset date and that he had at least a high school education. (R. 138.) Inasmuch
as the ALJ had found that Goree could perform a limited range of what he characterized as medium
work, and in light of the testimony of a vocational expert (“VE”) concerning jobs that could be
performed by someone with Goree’s vocational profile and RFC, the ALJ concluded that there
was other work that Goree could perform. (R. 139.) Accordingly, the ALJ found that Goree had

not been under a disability as defined in the Act at any time from June 1, 2015 to the date of his
decision. (R. 140.)
IV. DISCUSSION
Plaintiff contends that the ALJ’s finding as to his RFC, which led to the adverse finding at
Step Five, is the product of legal error and is not supported by substantial evidence. He sets forth
three bases for his request that the Court reverse the ALJ’s decision. First, he contends that the
ALJ improperly discounted RFC opinions rendered by his treating physician, Dr. Jones, and the
examining orthopedist, Dr. Cornejo. (Pl. Br. at 8.) Second, he asserts that the ALJ erred in finding
that he did not require a cane for ambulation. (Id. at 16.) Third, he asserts that the ALJ failed to
consider his work history when assessing the credibility of his complaints. (Id. at 19.)

A. The ALJ adequately supported his decision to give little weight to aspects of
the opinions of a treating physician and a consulting physician.
Plaintiff contends that “[t]he ALJ erred by failing to evaluate the medical opinion evidence
in accordance with the regulations, Agency policy and Third Circuit precedent” in that the ALJ
did not adopt opinions of Dr. Jones, his treating physician at the VA, and Dr. Cornejo, an
examining physician, despite their first-hand experience with and evaluation of him. (Pl. Br. at 3.)
He asserts at length that “[t]he ALJ did not give ‘good/specific/supported’ reasons for rejecting
the medical opinion evidence,” complaining principally that the ALJ discussed the opinions of Dr.
Jones and Cornejo “in isolation from each other, without acknowledging that they support each
other in their agreement that his ability to work is more limited that the ALJ’s RFC describes.”
(Id. at 4, 8 (all emphasis in original).). He complains that the ALJ’s failure to acknowledge “the
consistency between these critical pieces of evidence is clear error which undermines the ALJ’s
analysis of the evidence.” (Id. at 8.) He faults the ALJ for not manifesting his awareness of the
Agency’s preference for opinions from treating and examining sources and for failing to indicate

whether Dr. Jones’s status as a treating physician factored into his analysis of her opinion. (Id. at
8-9.) He criticizes the ALJ’s decision for “couch[ing]” his discussion of the opinions of Drs. Jones
and Cornejo “in a minimalistic and confusing reliance on the ‘reasons discussed’” earlier in the
decisions, which is “difficult to apply” and “fails to provide this Court with a logical bridge
between the evidence and the rejection of these two opinions.” (Id. at 9.) He argues that when the
record is viewed in the proper light, the opinions of Drs. Jones and Cornejo are consistent with and
supported by the record. He also contends that, inasmuch as the ALJ gave only “partial weight”
to the opinion of the state agency reviewing physician, the ALJ’s RFC finding was “based upon
his own interpretation of raw medical data.” (Id. at 14.) He asserts that their opinions establish

that he is limited to “light” exertional work which, coupled with his “advanced age” category and
history of skilled work, would direct a finding that he is disabled pursuant to Rule 202.06 of the
Medical Vocational Guidelines (“the Grids”). (Id. at 4-7.)2

2 Pursuant to this Rule, an individual in Plaintiff’s age category and with his educational
background who is limited to light, unskilled work is disabled. “Light work” involves “a good
deal of walking or standing,” or “sitting most of the time with some pushing and pulling of arm or
leg controls,” with frequent lifting of up to 10 lbs. and occasional lifting of 20 lbs. See 20 C.F.R.
§ 404.1567(b). Medium work is defined as involving “lifting no more than 50 pounds at a time
with frequent lifting or carrying of objects weighing up to 25 pounds.” Id., § 404.1567(c). The
ALJ found that Goree could stand and/or walk approximately 5 hours in an 8 hour workday but
that he had the ability to lift and carry 25 lbs. frequently and 50 lbs. occasionally, which is more
than that required for light work.
Following our review of the opinions at issue, and as we set forth below, we cannot agree
with Plaintiff that the ALJ violated applicable regulations when he reconciled the varied opinions
concerning Plaintiff’s physical and mental abilities and the comprehensive records in this case,
which included over 2,000 pages of materials from the VA. We first set out the standards by which
medical opinions are to be evaluated by adjudicators. We then analyze the opinions themselves

and the ALJ’s reconciliation of them with the other evidence of record. We address the opinions
in the order in which the ALJ discussed them: Dr. Chopra, the state agency reviewing physician
who gave an opinion in August 2017 based on review of the record compiled as of that date; Dr.
Cornejo, the consultative examiner who gave an opinion after a single examination in July 2017;
and Dr. Jones, the treating physician at the VA who rendered an opinion in September 2018 in
advance of Goree’s hearing.
1. Applicable regulations
The Commissioner’s regulations and rules emphasize that the RFC assessment that an
adjudicator makes “must always consider and address medical source opinions,” and that if the
RFC finding “conflicts with an opinion from a medical source, the adjudicator must explain why

the opinion was not adopted.” SSR 96-8p. Social Security Ruling 96-8p further provides that:
Medical opinions from treating sources about the nature and
severity of an individual’s impairment(s) are entitled to special
significance and may be entitled to controlling weight. If a treating
source’s medical opinion on an issue of the nature and severity of
an individual’s impairment(s) is well-supported by medically
acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in the case record,
the adjudicator must give it controlling weight.
SSR 96-8p (citing SSR 96-2p, “Titles II and XVI: Giving Controlling Weight to Treating Source
Medical Opinions,” and SSR 96-5p, “Titles II and XVI: Medical Source Opinions on Issues
Reserved to the Commissioner”) (emphasis added). The standards do not, however, specify that
adjudicators employ any particular language as they address medical source opinions as part of
their RFC assessment.
2. Dr. Chopra’s opinion
The first medical opinion that the ALJ described in his decision was that of Dr. Chopra,
who reviewed the state agency file on August 16, 2017 and completed a portion of the state agency

Disability Determination Transmittal form, supporting the decision rendered upon Goree’s request
for reconsideration. With regard to an evaluation of symptoms, Dr. Chopra found that Goree’s
statements about the intensity, persistence, and functionally limiting effects of his reported pain
and weakness were not substantiated by the objective medical evidence alone. In response to a
question about what factor he found most informative in assessing the credibility of Goree’s
statements about his symptoms, he identified Goree’s activities of daily living and the location,
duration, frequency and intensity of his pain and other symptoms. (R. 261.) When Dr. Chopra
completed his physical residual functional capacity assessment, he explained the various
limitations he included with reference to a paragraph of additional explanation. There he noted
that Goree indicated in his Disability Report form that his condition had not worsened since his

initial application, as well as the fact that he had not been “fully cooperative in completing
necessary forms.” (R. 263.) He recounted the observations from the consultative examination of
Dr. Cornejo, including that Goree was “in no distress,” had “normal transfers” from the
examination table, was “comfortable seated,” and showed “no focal deficits” in the upper
extremities. (Id.) With respect to the condition of Goree’s ankles, he noted that Dr. Cornejo
measured a full range of motion, with “no motor, sensory, [or] reflex deficits” in the lower
extremities, and “no laxity or instability” in the ankles. (Id.) He acknowledged that Dr. Cornejo
found a limited range of motion in the lumbar spine but no tenderness or spasms. (Id.) He also
commented on the “limp noted [by Dr. Cornejo] during examination that improved after leaving
examination office and [claimant] carried backpack on his back,” and the fact that Goree “used no
assistive device.” (Id.) Dr. Chopra recounted that the x-ray of the lumbar spine showed
degenerative disc disease but that the x-ray of the left ankle was normal. (Id.). He repeated that
Dr. Cornejo “noted inconsistencies in [range of motion of the lumbar] spine and gait,” and that
Goree had “good [ranges of motion] when distracted” and “no significant neurological deficits.”

(Id.)
The ALJ parsed the RFC opinion of Dr. Chopra -- which he found to be “partially
consistent with the evidence of record,” (R. 136) -- extensively in his decision. The ALJ gave
“great weight” to Dr. Chopra’s opinion that “the claimant can generally perform medium
exertion,” (R. 136), but “further [found] that the claimant is limited to standing or walking five
hours in an eight-hour workday,” as opposed to the six hours indicated by Dr. Chopra (Id.)
Accordingly, the ALJ accorded “partial weight” to Dr. Chopra’s opinion regarding Goree’s
exertional abilities. (Id.) He gave “great weight” to Dr. Chopra’s opinion that Goree did not
require an assistive device, noting evidence in the record that “the claimant generally walked with

a normal gait and demonstrated intact neurological functioning and a normal ability to stand and
walk when distracted (Exs. 4F, 5F and 10F),” and specifically noting Goree’s “improved gait until
[sic] leaving Dr. Cornejo’s examination.” (R. 136.) The ALJ gave “less weight,” however, to the
portions of Dr. Chopra’s opinion that minimized or overlooked effects of Goree’s tinnitus
impairment and certain effects of his ankle condition. (Id.) His reconciliation of these aspects of
Dr. Chopra’s opinion with the evidence of record yielded the ALJ’s additional findings that Goree
could never climb ladders, ropes or scaffolds (as opposed to “occasionally” do so); he could
occasionally crawl and climb ramps and stairs (as opposed to “frequently” do so); he could
frequently operate foot controls (despite limitations in the right lower extremity); and he could
occasionally be exposed to heights and moving mechanical parts. (R. 136, 262.)
3. Dr. Cornejo’s opinion
The second opinion concerning physical RFC that the ALJ described in his decision was
that of Dr. Cornejo, the examining but non-treating physician whose report was discussed at length

by Dr. Chopra. The ALJ included his own lengthy paragraph describing the July 2017 consultative
examination of Plaintiff by Dr. Cornejo, found at Exhibit 3F of the hearing record. The following
comments in the ALJ’s written decision discussing Dr. Cornejo’s report, which was found at
Exhibit 3F of the record, demonstrate the scope of his analysis and the conclusions he drew from
Dr. Cornejo’s report:
• “[Goree] was able to get on and off the examining table, and go from lying down to
sitting up position ([Ex. 3F)].). He was able to dress himself. He was comfortable in
the seated position during the interview (Id.). These findings are inconsistent with
disabling physicals [sic] symptoms.” (R. 132.)

• “Examination of his lower extremities showed no evidence of joint deformity or
instability ([Ex. 3F.]). There was a healed surgical scar along the right lateral ankle
consistent with right distal fibula fracture in 2014 (Id.). There was tenderness along
the medial malleolus of the left ankle. Otherwise, the claimant’s lower extremity joints
showed normal range of motion, normal reflexes and intact sensation (Id.). Notably,
he had full strength bilaterally in the muscle groups of the lower extremities…. There
was a negative anterior draw test of the left foot and no evidence of laxity or instability
of both ankles (Id.). These findings significant [sic] weaken the claimant’s allegations
of disabling lower extremity impairments.” (R. 132-33.)

• “There was no evidence of atrophy of the lower extremities as the circumferential
diameter measurement of both lower legs was equally 13” (Id.). This finding
significantly weakens the claimant’s allegations of reliance on an assistive device for
ambulation.” (R. 133.)

• “Examination of the claimant’s lumbar spine showed normal lordotic curve, decreased
flexion at 40 degrees; however, he was also able to bend his back to 90 degrees in order
to pull up his pains [sic] above is [sic] knees. ([Ex. 3F].). Notably, when distracted,
the claimant had good fluid mobility of the lumbar spine (Id.). These inconsistent
findings weaken the claimant’s allegations of disabling lumbar symptoms and support
an ability to occasionally crawl, and frequently stoop, kneel and crouch.” (R. 133.)

• “There was no significant spasm and tenderness to direct palpation along the
paralumbar musculature and lumbar spinous process, which is consistent with the
claimant’s positive response to muscle relaxants ([Ex. 3F].). Additionally, there was
no lower back pain or radicular symptoms on sitting or supine straight leg raising
maneuver testing, which weakens his allegations of radicular symptoms (Id.).” (R.
133.)

• “Notably, even though the claimant had a limp on the left during the evaluation, he was
observed walking with more a [sic] physiological gait while wearing a backpack as he
left the examination office ([Ex. 3F].). His limp on the left was less obvious, and he
was able to squat down, heel walk and toe walk (Id.). Moreover, he did not require the
use of an ambulation aide [sic] (Id.). These observations are inconsistent with the
claimant’s allegations that he cannot stand or walk for prolonged periods and requires
an assistive device for all ambulation.” (R. 133.)
(R. 132-33.). This lengthy discussion of the details of the narrative report that accompanied Dr.
Cornejo’s RFC assessment form demonstrates that the ALJ was certainly aware of the fact that Dr.
Cornejo personally examined Goree.
Dr. Cornejo rendered a contemporaneous opinion concerning Goree’s functional capacity,
which the ALJ addressed in the later portion of his decision in which he set out the various medical
opinions. He accepted Dr. Cornejo’s opinion only in part, explaining:
Dr. Cornejo opined the claimant may have difficulty with prolonged
walking and standing, can sit for a reasonable amount of time with
needed breaks, and has no significant balance limitations (Ex. 3F).
He further opined the claimant has good use of his upper extremities
for movements such as reaching and has good functionality of his
right and left hands (Id.). Dr. Cornejo opined the claimant can
handle fine and small sized objects, has no significant limitations to
fingering, such as picking and pinching objects (Id.). Finally, he
opined the claimant may have difficulty with heavy lifting, but can
do medium lifting occasionally as well as light and/or sedentary
activity frequently (Id.). For the same reasons discussed regarding
Dr. Chopra’s opinion, the undersigned gives great weight to Dr.
Cornejo’s opinion that the claimant is precluded from heavy lifting
and has no reaching, balancing or manipulative limitations, and little
weight to his remaining opinion because it is overly restrictive.
(R. 136.)
4. Dr. Jones’s opinion
The third and final medical opinion concerning physical RFC was rendered by Dr. Jones,
with whom Goree treated at the VA for left ankle and back pain. When Goree was working as a
forklift operator in an Amazon warehouse in 2015, and in light of complaints of back pain, Dr.
Jones authored a note asking that he not be required to engage in repeated lifting of more than 50
lbs. (R. 533.) Dr. Jones also prescribed medications for pain, including Flexeril, Motrin,
Tramadol, and Percocet. (R. 514.)
In advance of his November 2018 hearing before the ALJ, Goree obtained an opinion from
Dr. Jones as to the work-related limitations he faced as a result of various impairments. The

opinion was completed in form provided by counsel. The ALJ’s decision described it as follows:
Leah Jones, M.D., a treating physician, submitted [a] Treating
Source Statement dated September 2018 (Ex. 7F). Dr. Jones opined
the claimant will be absent from work four or more day[s] per
month, off task 25% of the workday[3] and requires the option to lie
down or recline for 30-minute periods, two times per day, and
requires the use of a cane if ambulating more than 50 feet ([Ex. 7F].).
She further opined the claimant can occasionally lift and carry ten
and 20 pounds, sit up to eight-hour[s] in an eight-hour workday, and
stand and/or walk one hour in an eight-hour workday (Id.). She
opined the claimant can occasionally reach overhead, push and pull,
frequently reach in all other directions, and never perform any
postural maneuvers (Id.). Dr. Jones opined the claimant can rarely
use left foot controls and frequently use right foot controls (Id.).
Finally, she opined the claimant can never work around unprotected
heights, rarely operate a vehicle and work around extreme cold,
occasionally work around extreme heat and vibrations, and

3 The form provided a number of percentage options from which to choose in response to the
question of the percentage of the day that symptoms would interfere with attention and
concentration to perform even simple tasks at work. (R. 2408.)
continuously work around moving mechanical parts and pulmonary
irritants (Id.).
(R. 136-37 (emphasis added).) After reciting these aspects of Dr. Jones’s opinion, and before
moving on to address the psychiatric opinions offered in the case, the ALJ concluded the above
paragraph with the statement: “For the same reasons discussed regarding Dr. Chopra’s opinion, I
give little weight to Dr. Jones’ opinion.” (R. 137.)
5. The ALJ adequately reconciled the various opinions concerning
Goree’s physical RFC.
As to Plaintiff’s first point, that the ALJ did not display an awareness that he was giving
little weight to a treating physician opinion, we do not find so simple a rule to apply. The ALJ
demonstrated that he was aware of Dr. Jones’s relationship with Plaintiff, as his paragraph opened
with the descriptor of Dr. Jones as “a treating physician” and her opinion was set forth in a
document entitled “Treating Source Statement.” (R. 136.).
As to Plaintiff’s second point, that the ALJ did not reflect an awareness of the consistency
of Dr. Jones’s opinion with that of Dr. Cornejo, we again believe Plaintiff has identified no error.
There were important differences between the opinions of Drs. Cornejo and Jones. Dr. Cornejo
was not asked to opine about whether Goree’s “symptoms” – which from Dr. Jones’s perspective

included depression, PTSD, and insomnia (R. 2408) – would interfere with attention and
concentration or lead to absences from work, as Dr. Jones found. She found a cane was needed to
ambulate effectively, whereas Dr. Cornejo observed otherwise and specifically opined that a cane
was not used nor required. (R. 704.) While there was consistency regarding Dr. Cornejo’s
observation that Goree “may have difficulty with prolonged walk[ing]” and could do medium
lifting only occasionally, he was not asked to opinion on the number of hours that Plaintiff could
walk or stand. (R. 702)
As we review the “reasons discussed regarding Dr. Chopra’s opinion,” to which the ALJ
referred when stating the weight he gave to the opinions of Drs. Cornejo and Jones, we find that it
provides sufficient justification for why he gave little weight to Dr. Jones’s opinion concerning
Goree’s projected absences from work, a need for the option to lie down or recline for two 30-
minute periods, a limitation to only 1 hour of standing or walking in an eight-hour workday, and

the need for a cane for ambulation beyond 50 feet. The ALJ’s emphasis on Dr. Cornejo’s objective
examination results and observations suggesting exaggeration by Plaintiff undermined his
credibility regarding the extent that his ankle impairment precluded effective ambulation without
a cane and that lifting and carrying restrictions rendered him unable to perform medium work.
The ALJ clearly stated his finding that Goree’s statements concerning the intensity,
persistence, and limiting effects of the symptoms caused by his medically-determinable
impairments were “not entirely consistent” with the medical evidence and other evidence in the
record. (R. 130.). With regard to Goree’s physical limitations, he cited to “the claimant’s positive
response to conservative care in conjunction with his consistently normal neurological functioning

with some paraspinal tenderness,” leading him to find that Goree could “perform medium
exertional activities with the exception of standing or walking five hours in an eight-hour weekday,
occasionally climb ramps and stairs, never climb ladders, ropes or scaffolds, and frequently
balance, stoop, kneel and crouch.” (R. 130-31.) He further found that Goree’s “generally intact
gait despite some left ankle symptoms is not consistent with his allegations of disabling left ankle
symptoms and need for an assistive device.” (R. 131.) He summarized that Goree’s “left ankle
impairment was treated conservatively throughout the relevant period and clinical examinations
generally documented some tenderness and stiffness.” (Id.) He continued that “[w]hile there is
evidence of some antalgic gait due to left ankle pain, the claimant generally walked with a normal
gait and demonstrated normal ability to stand and walk when distracted.” (Id.) The ALJ concluded
that, “[f]or these reasons, the undersigned finds that the claimant does not require an assistive
device, and can perform medium exertional activities with the exception or standing or walking
five hours in an eight-hour workday, occasionally climb ramps and stairs, never climb ladders,
ropes or scaffolds, and frequently operate of [sic] foot controls.” (R. 131-32.)

It is clear that the ALJ was aware of the different opinions in this case by the three different
medical sources, each of whom had a different role and perspective. He demonstrated his
understanding of the opinions and clearly stated what aspects he took from each, relying
principally on the opinion of the state agency doctor who had the most knowledge of the disability
system and who had the benefit of a substantial record in addition to the report of the experience
of Dr. Cornejo. We conclude that the ALJ cited to sufficient evidence supporting his decision to
decline to adopt the suggestions in Dr. Cornejo’s opinion regarding prolonged standing/walking
and exertional level, as well as the more particular opinions of Dr. Jones in these regards.
B. The ALJ’s finding in the RFC assessment that Plaintiff did not require the use
of a cane was supported by substantial evidence.
Plaintiff next contends that the RFC finding was not supported by substantial evidence in
that the finding did not reflect a need for a cane despite evidence that he often used one. While he
does not point to record evidence that a physician prescribed him a cane, Plaintiff recounts the
many instances in the record in which it was noted that he used a cane and notes that “no physician
opined that a cane was not necessary.” (Pl. Br. at 16 (emphasis added).) He faults the ALJ for

supporting the notion that he had a normal gait by citing to records involving treatment for other
impairments. He acknowledges one record cited by the ALJ from an orthopedic visit at the VA in
which the provider noted that when he was distracted, Plaintiff was able to stand and walk. (R.
763.) Plaintiff counters that the physician there at least indicated he would benefit from a brace
and that x-rays would be repeated in 4 months. (Pl. Br. at 17; R. 761-64.)
Plaintiff’s contention here essentially invites the Court to re-weigh the evidence. The ALJ
was well aware of the question of whether Plaintiff required a cane in order to walk. He addressed
the issue in the context of his Step Two analysis of Listings 1.02 (Major Dysfunction of a Joint)

and 1.04 (Disorders of the Spine). (R. 127.) He relied heavily on the fact that during the CE
examination in July 2017, Goree walked with a limp during the examination yet upon leaving the
office, was observed “with a more physiological gait,” in which the limp was less obvious and did
not require him to use an ambulation aid. (Id.). The ALJ also continued:
Furthermore, during this examination, the claimant stated that he has
limped on the left foot since 1983; however, this allegation is
inconsistent with the physical examination showing no evidence of
atrophy of the left leg compared to the right leg (Ex. 3F/5).
(R. 127.) These facts provided substantial evidence upon which the ALJ could discredit Plaintiff’s
statements about the need for a cane at that time and about his having had ambulation difficulties
in the past. We do not find this argument to require the ALJ’s decision be vacated.
C. The ALJ did not commit reversible error in evaluating Goree’s credibility
without reference to his work history.
In his final argument seeking remand, Plaintiff contends that the ALJ’s assessment of the
credibility of his complaints is also “defective” in that the ALJ failed to acknowledge his “strong
work history.” (Pl. Br. at 19.) He points to 20 CFR § 404.1529(c)(3), SSR 96-8p, and SSR 16-3p
regarding the relevance of a claimant’s work history and work attempts when assessing the
credibility of a claimant’s contention that he is unable to work due to his impairments. He notes
that the record documented qualifying earnings in 110 quarters over his 38-year work history,
including 5 years of service in the U.S. Navy. (Id.)
The ALJ recounted Plaintiff’s work history in his analysis at Step Four, which requires a
comparison of the RFC to the claimant’s past work. There he noted that Goree had a past relevant
work history as a maintenance electrician, a building maintenance worker, and a forklift operator
– all of which were semiskilled or skilled positions – and accepted that Goree was now unable to
perform that work due to his mental deterioration. (R. 138.) With respect to Plaintiff’s work

history overall, the ALJ’s decision also referred to Plaintiff’s military service, during which he
incurred the original injury to which he attributed his left ankle pain. (R. 131.) The ALJ also
recognized that Goree engaged in work as an electrician during the second and third quarters of
2016, leading to an analysis of whether the work amounted to substantial gainful activity. (R.
126.) See also R. 131 (noting that Goree postponed surgery offered to him for left ankle “because
he had just started a new job”).
The ALJ did not explicitly reconcile Plaintiff’s substantial work record with his findings
that Plaintiff’s complaints about his functional limitations were not entirely consistent with the
record as a whole. But the Regulations did not require the explicit discussion that Plaintiff

suggests. They instead require only that the ALJ “consider all of the evidence presented, including
information about [the claimant’s] prior work record, [his] statements about [his] symptoms,
evidence submitted by [his] medical sources, and observations by [Agency] employees and other
persons.” 20 CFR §404.1529(c)(3).4 The ALJ satisfied his obligation in this regard.
An appropriate order follows.

4 The other sources cited by Plaintiff in addition to this Regulation, SSR 96-8p and SSR 16-3p, do
not appear to require anything further of ALJs as to consideration of a claimant’s prior work record
apart from what is necessarily encompassed within Steps Four and Five of the sequential
evaluation.

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10399860. Public record. Not legal advice.