Martes v. Comm'r of Soc. Sec.
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Opinion
GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Jaron Anthony Martes brings this action pursuant to
I. BACKGROUND
A. Procedural History
Martes applied for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on November 5, 2013. See Certified Administrative Record, filed Jan. 8, 2018 (Docket # 15) ("R."), at 10, 73-74. He alleged that his disability began on July 1, 2013, the date he was injured in a car accident, when he was 33 years old. R. 10, 17, 286.
The Social Security Administration ("SSA") denied Martes's applications and Martes sought review by an Administrative Law Judge ("ALJ"). R. 75, 83, 85. An initial hearing was held on January 12, 2016, before an ALJ. R. 47-60. A supplemental hearing was held on June 15, 2016, before the same ALJ. R. 31-46. In a written decision dated August 22, 2016, the ALJ found Martes not disabled within the meaning of the Act. R. 7-19. On May 31, 2017, the Appeals Council denied Martes's request for review of the ALJ's decision, making the ALJ's decision the final decision of the Commissioner. R. 1-6. This action followed.
B. The Hearing Before the ALJ
Martes was represented by attorney David Levine at his hearings before the ALJ. R. 31, 47. Because the ALJ had not received any records for medical appointments occurring after May 2014 prior to the initial hearing held in January 2016, the initial hearing was limited to oral testimony from Martes as to his treatment during the period of May 2014 through January 2016. See R. 50-52. Martes testified to seeing two physicians in that time: Dr. Emmanuel Lambrakis for pain management and Dr. Eli Witt for psychiatric counseling. R. 55, 56-57. He also referred to a primary care physician at Montefiore Medical Center whom he saw for referrals. R. 54.
At the June 15, 2016, hearing, Martes testified that prior to the car accident he worked in customer service at a retail store, as well as "some delivery and moving type work," and maintenance. R. 36. After the accident, however, he began to experience knee, neck, and back pain. R. 37, 38-39. He felt radiating pain from his neck into his spine and his hands and arms sometimes shook due to his neck pain. R. 43. He also experienced sharp pains in his lower back, radiating "sometimes" to his legs. R. 43. Because of his pain, he estimated that he could stand no more than 15 minutes at a time, R. 44, and that in an eight-hour period he would spend "most of the time ... laying down somewhere," R. 45. If he instead spent the time sitting, he would experience back pain. R. 45. To cope with this pain, Martes takes several medications - namely, Oxycodone, Xanax, and Motrin - that cause him to experience incoherence, difficulty walking, dizziness, and memory problems. R. 37-38. As a result of the pain and the side effects of his pain medication, he said he could no longer perform his prior work. R. 37. Martes underwent surgery on his knee, but he did not have any improvement as a result. R.
*75538. He turned down a recommendation that he undergo a second surgery because he did not want it. R. 38. Martes also reported seeing a psychiatrist for anxiety and trouble sleeping. R. 39.
Martes was 36 years old at the time of the hearing. R. 35. He testified to having two children and recently living with them, though he had since moved in with his mother. R. 36, 40. He stated that he spent most of his days sleeping and reported that he is unable to take care of his children as a result of the drowsiness associated with his medications, though he used to take care of them. R. 40-41. He did not drive or perform activities of daily living, like cleaning or cooking, relying on his mother for these activities. R. 41. He also did not "associate with public transportation" because of the side effects from his medication. R. 42. He used to have hobbies, but no longer had any. R. 42. Instead he spends his time "try[ing] to sleep," so that the effects of his medication "wear off." R. 41.
C. The Medical Evidence
Both Martes and the Commissioner have provided summaries of the medical evidence contained in the administrative record. See Pl. Mem. at 1-5; Comm'r Mem. at 4-10. The summaries are substantially consistent with each other. The Court had directed the parties to specify any objections they had to the opposing party's summary of the record, see Scheduling Order, filed Jan. 10, 2018 (Docket # 16), ¶ 5, and neither party has done so.2 Accordingly, the Court adopts Martes's and the Commissioner's summaries of the medical evidence as accurate and complete for purposes of the issues raised in this suit. We discuss the medical evidence pertinent to the adjudication of this case in section III below.
D. The ALJ's Decision
The ALJ denied Martes's application for DIB and SSI on August 22, 2016. R. 7. Following the five-step test set forth in SSA regulations, the ALJ found at step one that Martes had not engaged in "substantial gainful activity since July 1, 2013, the alleged [disability] onset date." R. 12. At step two, the ALJ found that Martes had the following severe impairments: "status post arthroscopic repair of the left knee, L4-5 disc bulge and straightening of the lumbar lordosis, disc bulges of the cervical spine at C4-C5 and C5-C6, as well as straightening of the cervical lordosis."
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GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Jaron Anthony Martes brings this action pursuant to
I. BACKGROUND
A. Procedural History
Martes applied for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on November 5, 2013. See Certified Administrative Record, filed Jan. 8, 2018 (Docket # 15) ("R."), at 10, 73-74. He alleged that his disability began on July 1, 2013, the date he was injured in a car accident, when he was 33 years old. R. 10, 17, 286.
The Social Security Administration ("SSA") denied Martes's applications and Martes sought review by an Administrative Law Judge ("ALJ"). R. 75, 83, 85. An initial hearing was held on January 12, 2016, before an ALJ. R. 47-60. A supplemental hearing was held on June 15, 2016, before the same ALJ. R. 31-46. In a written decision dated August 22, 2016, the ALJ found Martes not disabled within the meaning of the Act. R. 7-19. On May 31, 2017, the Appeals Council denied Martes's request for review of the ALJ's decision, making the ALJ's decision the final decision of the Commissioner. R. 1-6. This action followed.
B. The Hearing Before the ALJ
Martes was represented by attorney David Levine at his hearings before the ALJ. R. 31, 47. Because the ALJ had not received any records for medical appointments occurring after May 2014 prior to the initial hearing held in January 2016, the initial hearing was limited to oral testimony from Martes as to his treatment during the period of May 2014 through January 2016. See R. 50-52. Martes testified to seeing two physicians in that time: Dr. Emmanuel Lambrakis for pain management and Dr. Eli Witt for psychiatric counseling. R. 55, 56-57. He also referred to a primary care physician at Montefiore Medical Center whom he saw for referrals. R. 54.
At the June 15, 2016, hearing, Martes testified that prior to the car accident he worked in customer service at a retail store, as well as "some delivery and moving type work," and maintenance. R. 36. After the accident, however, he began to experience knee, neck, and back pain. R. 37, 38-39. He felt radiating pain from his neck into his spine and his hands and arms sometimes shook due to his neck pain. R. 43. He also experienced sharp pains in his lower back, radiating "sometimes" to his legs. R. 43. Because of his pain, he estimated that he could stand no more than 15 minutes at a time, R. 44, and that in an eight-hour period he would spend "most of the time ... laying down somewhere," R. 45. If he instead spent the time sitting, he would experience back pain. R. 45. To cope with this pain, Martes takes several medications - namely, Oxycodone, Xanax, and Motrin - that cause him to experience incoherence, difficulty walking, dizziness, and memory problems. R. 37-38. As a result of the pain and the side effects of his pain medication, he said he could no longer perform his prior work. R. 37. Martes underwent surgery on his knee, but he did not have any improvement as a result. R.
*75538. He turned down a recommendation that he undergo a second surgery because he did not want it. R. 38. Martes also reported seeing a psychiatrist for anxiety and trouble sleeping. R. 39.
Martes was 36 years old at the time of the hearing. R. 35. He testified to having two children and recently living with them, though he had since moved in with his mother. R. 36, 40. He stated that he spent most of his days sleeping and reported that he is unable to take care of his children as a result of the drowsiness associated with his medications, though he used to take care of them. R. 40-41. He did not drive or perform activities of daily living, like cleaning or cooking, relying on his mother for these activities. R. 41. He also did not "associate with public transportation" because of the side effects from his medication. R. 42. He used to have hobbies, but no longer had any. R. 42. Instead he spends his time "try[ing] to sleep," so that the effects of his medication "wear off." R. 41.
C. The Medical Evidence
Both Martes and the Commissioner have provided summaries of the medical evidence contained in the administrative record. See Pl. Mem. at 1-5; Comm'r Mem. at 4-10. The summaries are substantially consistent with each other. The Court had directed the parties to specify any objections they had to the opposing party's summary of the record, see Scheduling Order, filed Jan. 10, 2018 (Docket # 16), ¶ 5, and neither party has done so.2 Accordingly, the Court adopts Martes's and the Commissioner's summaries of the medical evidence as accurate and complete for purposes of the issues raised in this suit. We discuss the medical evidence pertinent to the adjudication of this case in section III below.
D. The ALJ's Decision
The ALJ denied Martes's application for DIB and SSI on August 22, 2016. R. 7. Following the five-step test set forth in SSA regulations, the ALJ found at step one that Martes had not engaged in "substantial gainful activity since July 1, 2013, the alleged [disability] onset date." R. 12. At step two, the ALJ found that Martes had the following severe impairments: "status post arthroscopic repair of the left knee, L4-5 disc bulge and straightening of the lumbar lordosis, disc bulges of the cervical spine at C4-C5 and C5-C6, as well as straightening of the cervical lordosis."
II. GOVERNING STANDARDS OF LAW
A. Scope of Judicial Review Under 42 U.S.C. § 405 (g)
A court reviewing a final decision by the Commissioner "is limited to determining whether the [Commissioner's] conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Selian v. Astrue,
"Even where the administrative record may also adequately support contrary findings on particular issues, the ALJ's factual findings must be given conclusive effect so long as they are supported by substantial evidence." Genier v. Astrue,
B. Standard Governing Evaluation of Disability Claims by the Agency
The Social Security Act defines the term "disability" as the "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."
To evaluate a Social Security claim, the Commissioner is required to examine: "(1) the objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience." Mongeur v. Heckler,
Regulations issued pursuant to the Act set forth a five-step process that the Commissioner must use in evaluating a disability claim. See
C. The "Treating Source" Rule
In general, the ALJ must give "more weight to medical opinions" from a claimant's treating sources when determining if the claimant is disabled. See
If the ALJ does not give controlling weight to a treating source's opinion, the ALJ must provide "good reasons" for the weight given to that opinion or face remand. See Greek,
*759III. DISCUSSION
Martes raises five grounds for reversing the ALJ's decision: (1) the ALJ "erred in not fully crediting ... Mr. Martes's allegation of severe pain," Pl. Mem. at 7; (2) the ALJ improperly applied the treating source rule, id. at 9; (3) the ALJ did not consider the side effects of Martes's medications in compiling his RFC, id. at 11; (4) the ALJ did not consider Martes's non-severe impairments in compiling his RFC, id. at 12; and (5) the ALJ improperly applied the Medical-Vocational Guidelines in finding that Martes was not disabled under the Act, id. at 12. We discuss each next.
A. Credibility of Claimant's Allegations of Severe Pain
The ALJ found Martes's "statements concerning the intensity, persistence and limiting effects of [his left knee and back pain] ... not entirely consistent with the medical evidence and other evidence in the record." R. 17. The ALJ explained that Martes's treatment "since his accident has been routine in nature" and that Martes had "shown good improvement with treatment, including good recovery after a knee surgery." R. 17. Additionally, the ALJ noted that "examination results and ... his testimony reveal no significant range of motion limitations or ambulation problems," R. 17, even if, as the ALJ recognized, Martes suffers "periods of significant limitations due to his knee and ongoing back pain that warrant ... limitations," R. 16. The ALJ also reasoned that the "overall record" and "the opinions provided" failed to support allegations that Martes's left knee and back pain rendered him completely disabled. R. 17.
Martes contends that the ALJ's determination of his credibility was "erroneously" based on "[a] lack of objective medical findings" to support his allegations of "severe pain." Pl. Mem. at 7-9. He argues that "there, in fact, were clinical findings to support [his] claim of severe pain," which the ALJ erroneously ignored or mischaracterized. Id. at 8. He also contends that it was legal error for the ALJ to discredit his complaints of disabling pain based solely on the lack of corroborating objective medical findings. Id. at 8.
"It is the function of the [Commissioner], not [the reviewing court], to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant." Carroll v. Sec'y of Health & Human Servs.,
With respect to the ALJ's assertion that "the claimant's functioning noted in examination results and during his testimony reveal no significant range of motion limitations or ambulation problems," R. 17, this finding is supported by the notes and opinions of treating physician Dr. Norman Sveilich and consulting examiner Dr. Seema Rai, as well as by portions of Martes's testimony. Following arthroscopic surgery on Martes's left knee, Dr. Sveilich diagnosed Martes with a "[l]eft knee ACL sprain grade 1." R. 289.3 Seven weeks after the surgery, Dr. Sveilich noted that "[p]ain was elicited at the extreme limits of the range of motion," and he observed tenderness on palpation of Martes's knee, but otherwise observed that Martes exhibited normal flexibility and extension of the knee, full strength with no muscle atrophy, and normal gait and stance. R. 327-28. Nine months after surgery, in May 2014, Dr. Sveilich observed that Martes experienced knee pain "throughout the range of motion" and that "ambulation required crutches," but also found that Martes exhibited a full range of motion and had no muscle atrophy, balance issues, or gait and stance issues. R. 331. He also remarked that Martes was "[d]oing well." R. 330. These relatively mild findings are consistent with the ALJ's determination that Martes suffered from no "significant" range of motion limitations, though he might suffer occasional pain upon motion. Dr. Sveilich's May 2014 notation supporting the use of crutches reflects ambulatory limitations, but the ALJ could have looked to Dr. Rai's February 2014 opinion that Martes's use of a cane was "not medically necessary." R. 315. Dr. Rai also observed that Martes could "walk on heels and toes without difficulty," was "[a]ble to rise from [a] chair without difficulty," and exhibited a full range of motion in his back, knees, and neck. R. 315-16. Thus, Dr. Rai's notes and opinions support the ALJ's finding. As for Martes's testimony at the hearing, Martes testified to driving and taking care of his young child except when on Oxycodone, and did not assert any ambulatory or range of motion limitations due to knee and back pain when asked to identify his disabling symptoms. See R. 39-41. This testimony is consistent with the ALJ's finding that Martes experienced no range of motion limitations or ambulatory problems.
Martes contends his doctors observed "limited range of motion" and that he walked with "an antalgic gait," Pl. Mem. at 8, but these remarks either were inconsistent with Dr. Sveilich's and Dr. Rai's notes, or predated significant treatment for Martes's pain. For instance, only one physician, Dr. Emmanuel Lambrakis (Martes's pain management specialist) observed that Martes walked with an antalgic gait "due to muscle spasm on the low back," R. 375, but the notes of Dr. Sveilich and Dr. Rai contradict this finding. It is within an ALJ's discretion to resolve "genuine conflicts in the medical evidence." Veino,
The record also supports the ALJ's assertion that his treatment has been "routine in nature" and that "he has shown good improvement with treatment, including good recovery after a knee surgery." R. 17. Following his arthroscopic knee surgery in September 2013, the operating physician, Dr. Sveilich, recommended that Martes "cease offending physical activity," attend physical therapy, perform "[h]ome exercises for strengthening" and continue using crutches. R. 325, 328, 332, 341, 410. The recommended physical therapy consisted of biking and elliptical and strength training, R. 410, and Martes later told Dr. Seema Rai he does these exercises, as directed by his doctor, and "uses the bike, as well as weights for his legs," R. 313. Dr. Sveilich noted a week after surgery and then nine months after surgery that Martes was "[d]oing well," R. 324, 330, though Martes continued to report pain in his left knee, R. 330. Dr. Sveilich did recommend a second surgery because of "patient's complaints, [the] results of [a] clinical examination with positive orthopedic findings[,] and [a] significant lack of patient's improvement to conservative nonsurgical treatment," R. 333; however, Martes turned down this surgery, R. 38, which in any event was to be only for the purpose of "properly diagnos[ing] [Martes's] condition ... to provide more specific and maximal effective treatment for the patient," R. 333. Martes later told Dr. Rai that "[h]e has had some improvement with previous physical therapy." R. 313. In the two years after Dr. Sveilich's second recommendation for surgery, the record notes on Martes condition reflect an unchanged course of "conservative treatment," R. 367, consisting of the use of Oxycodone and other pain medications which he said reduced his pain, see R. 366-88. For his back pain, Martes's treatment was limited to pain medication and physical therapy, and one-time trigger point injections. R. 274-75, 313, 366-88. Martes argues that these records "show [his] condition did not improve with treatment and that his severe pain and symptoms remained unchanged." Pl. Mem. at 9. In doing so, Martes relies heavily on the treating notes of his pain management physician, Dr. Lambrakis.
*762but see R. 274 (Dr. Pavlova recording Martes's back pain as 9/10 in July 2013 prior to any trigger point injections or physical therapy). Thus, Dr. Lambrakis's notes on Martes's pain to the contrary, the record generally supports the ALJ's finding on Martes's treatment.
As for the "opinions provided," none support Martes's asserted physical limitations. Dr. Rai, whose opinion received "great weight" from the ALJ, R. 16, opined that Martes had "no limitations," R. 316. Dr. Pavlova opined in July 2013 that Martes was "partially disabled," R. 274, but by August 2013 Dr. Pavlova concluded that Martes was "not disabled," R. 280. Last, Dr. Eli Witt, Martes's treating psychiatrist, only opined on Martes's mental functioning. See R. 336-38. Thus, substantial evidence supports all of the ALJ's reasons for discounting Martes's subjective statements about the disabling effects of his impairments.4
Insofar as Martes argues that the objective medical evidence supported his subjective complaints of pain, Pl. Mem. at 7-8; Pl. Reply Mem. at 3, there was also evidence in the record that rebuts this finding. See generally Johnson,
Finally, to the extent Martes argues that an ALJ may not rely on objective medical evidence to "discredit complaints of pain," Pl. Mem. at 7-8, we disagree. As previously noted, "it is the function of the Commissioner ... to appraise the credibility of witnesses, including the claimant." Campbell v. Astrue,
Martes points to Aubeuf v. Schweiker,
Additionally, case law holds that an ALJ "is not required to accept the claimant's subjective complaints without question; he may exercise discretion in weighing the credibility of the claimant's testimony in light of the other evidence in the record." Barry v. Colvin,
B. Application of Treating Source Rule
In discussing the record and evaluating Martes's RFC, the ALJ assigned "great weight" to consulting examiner Dr. Rai's opinion that Martes "had no limitations," R. 16, but "limited weight" to the opinion of treating source Dr. Pavlova that Martes was "partially disabled" and "little weight" to the opinion of Dr. Witt concerning the effect of physical pain on Martes's mental functioning, R. 16-17. The ALJ did not *764refer to treating sources Dr. Sveilich, Dr. Gorum, or Dr. Lambrakis by name, but in summarizing the record the ALJ noted their reports that Martes had reported ongoing pain to them and noted their treatments or recommendations. R. 16. Martes contends the ALJ should have given controlling weight to Martes's treating physicians "rather than to an outdated opinion from a one-time [consulting examiner]." Pl. Mem. at 11. In so arguing, Martes makes reference only to Dr. Pavlova, Dr. Sveilich, Dr. Gorum, and Dr. Lambrakis. See id. at 10. We find no error in the ALJ's use of her discretion to resolve conflicts between the medical opinions in the record.
To start with, the ALJ did not err in according "limited weight" to Dr. Pavlova's opinion that Martes was "partially disabled." See R. 16, 274. The ALJ reasoned that Dr. Pavlova's July 2013 opinion merited little weight because "it was drafted a few days after the claimant's accident that caused his alleged disability" and thus provided only a snapshot of Martes's condition before any treatment. R. 16-17. It was also contradicted a month later by Dr. Pavlova's August 2013 opinion that Martes was "not disabled from his previous work." R. 16, 280. Because the July 2013 opinion was quickly contradicted by the August 2013 opinion, and both opinions pre-dated Martes's September 2013 surgery, see R. 289, the ALJ reasonably concluded that the July 2013 opinion was due no more than "limited weight," R. 16. Of course, an ALJ need not defer to a treating source's opinion on the ultimate issue of disability and can discount a vague opinion rendered in simplistic categories of "total, partial, and no" disability, as Dr. Pavlova's opinion was in this case. See Snell v. Apfel,
The record also supports the ALJ's reasons for giving "great weight" to Dr. Rai's February 2014 opinion that Martes "had no limitations" and did not need to use a cane. R. 16. As the ALJ wrote, Dr. Rai was "an examining source who provided a full length examination and is familiar with the Agency guidelines on assessing a claimant's functioning." R. 16; see R. 313-17. The ALJ further noted that Dr. Rai's observations of minimal abnormalities on examination and in laboratory results were "consistent with the claimant's complaints that support medium levels of pain but do not purport significant functional limits." R. 16. A review of Dr. Rai's examination confirms these observations. On examination, Dr. Rai observed that Martes could "walk on heels and toes without difficulty," that he "[n]eeded no help changing for [the] exam or getting on or off [the] exam table," and that he was "able to rise from [a] chair without difficulty." R. 315. A musculoskeletal and neurological examination revealed nothing abnormal, though an x-ray of the back revealed straightening of the lumbosacral spine. R. 315-16, 318. These objective medical observations support Dr. Rai's finding that Martes endured no functional limitations. Moreover, as the ALJ noted, Martes had reported to Dr. Rai that he experiences constant knee pain that he would place as a six or seven on a ten-point scale, which worsens "with bending his knee or walking for extended periods," but also that "[h]e has had some improvement *765with previous physical therapy" and that he "currently does exercises in the gym, as directed by his physician." R. 313. Martes also reported to Dr. Rai that his back pain was a three to five on a ten-point scale. R. 313. Thus, as the ALJ noted, Dr. Rai's opinion was consistent with Martes's reports of medium levels of pain that do not translate to "significant functional limit[ations]." R. 16.
Dr. Rai's findings were also supported by Dr. Sveilich's observation that Martes was "doing well," R. 324, 330, and the record of only mild objectively verifiable injuries, see, e.g., R. 289-90 (Dr. Sveilich diagnosing Martes with a grade 1 ACL sprain post-operation). On this record, the ALJ reasonably exercised her discretion in affording great weight to Dr. Rai's opinion. See Diaz v. Shalala,
Martes claims Dr. Rai "did not evaluate [his] pain and ... was unaware of the MRIs that showed [he] had a cervical disc herniation and multiple lumbar disc bulges with impingement." Pl. Mem. at 10. However, the ALJ incorporated such limitations expressly in her decision that Martes "warrant[ed] additional limitations beyond those noted in Dr. Rai's opinion." R. 16. Specifically, after noting what parts of Dr. Rai's opinion were consistent with the evidence, the ALJ noted that the record showed "cervical spine impairments" and that "reveal[ed] that [Martes's] pain has not been completely eliminated." R. 16. Additionally, although Martes asserts that Dr. Rai erred by "not address[ing] whether [he] had side effects from his medications," Pl. Mem. at 10, the record does not support that Martes in fact suffered any side effects at the time of Dr. Rai's examination. See infra Section III.C. Accordingly, the ALJ had no such basis for reducing the weight given to Dr. Rai's opinion. Martes's final claims are that Dr. Rai's opinion merited less weight because it was from two years before the ALJ issued his decision and thus did not include two years worth of information, Dr. Rai "had no treating relationship with him," and Dr. Rai "examined [ ] Martes only once." Pl. Mem. at 10. Again, the ALJ accounts for these factors in the opinion. R. 16. When discussing why the ALJ believes Martes "warrant[s] additional limitations beyond those noted in Dr. Rai's opinion," the ALJ cites to Martes's "ongoing complaints," "ongoing treatments," and "recent treatment." R. 16. The ALJ also describes Dr. Rai as a consultative examiner who saw Martes only once, on February 6, 2014. R. 16. We thus believe the ALJ already accounted for these factors in her decision to give great, but not controlling weight to Dr. Rai's opinion. As noted, it is within an ALJ's discretion to resolve "genuine conflicts in the medical evidence." Veino,
While Martes did not make the argument, we note that the ALJ did not err by not referring to the opinions of Dr. Sveilich, Dr. Gorum, and Dr. Lambrakis, see *766Pl. Mem. at 10, given that none of these treating sources actually gave medical opinions - the only statements that are due deference under the treating source rule.
C. Consideration of the Side Effects of Medication
Martes claims that the ALJ erred in not considering the impact of side effects of medication on his RFC. Pl. Mem. at 11-12. At his hearings before the ALJ, Martes claimed he experiences incoherence, difficulty walking, dizziness, and memory problems as a result of taking Oxycodone. R. 37-38. He also separately reported drowsiness or a general fatigue from his medications. R. 41, 358. The record shows that Martes was also prescribed Flexeril, Motrin, Voltaren, and Xanax. R. 374, 378, 388. Martes notes that his reported symptoms are consistent with the listed side effects for these drugs. Pl. Mem. at 3 nn. 2-3, 5 nn. 4-5.
Social Security regulations require the Commissioner to consider "[t]he type, dosage, effectiveness, and side effects of any medication you take or have taken to alleviate *767your pain or other symptoms."
statements about your pain or other symptoms will not alone establish that you are disabled. There must be objective medical evidence from an acceptable medical source that shows you have a medical impairment(s) which could reasonably be expected to produce the pain or other symptoms alleged and that, when considered with all of the other evidence (including statements about the intensity and persistence of your pain or other symptoms which may reasonably be accepted as consistent with the medical signs and laboratory findings), would lead to a conclusion that you are disabled.
...
Your symptoms, such as pain, fatigue, shortness of breath, weakness, or nervousness, will not be found to affect your ability to do basic work activities unless medical signs or laboratory findings show that a medically determinable impairment(s) [which could reasonably be expected to produce the pain or other symptoms alleged] is present.
In this case, the ALJ did not expressly address in her decision Martes's alleged side effects. Martes argues this is a ground for remand. Pl. Mem. at 11-12. An ALJ need not, however, explicitly address each and every statement made in the record that might implicate her evaluation of a claimant's credibility as long as "the evidence of record permits us to glean the rationale of an ALJ's decision." Cichocki,
*768R. 17, we conclude that the ALJ considered Martes's claim of debilitating side effects and found it wholly unsupported. Given the lack of any medical records corroborating Martes's claimed side effects, we find no error in the ALJ's decision not to incorporate the side effects into a discussion of Martes's RFC or into the resulting RFC itself. See Sabater v. Colvin,
Martes cites Arias v. Astrue,
D. Consideration of Non-Severe Impairments When Compiling RFC
Martes asserts that the ALJ failed to consider his non-severe impairments - specifically, the effect of his diagnosis for "adjustment reaction disorder with mixed emotional features" and high blood pressure - in reaching an RFC determination. Pl. Mem. at 12. Martes asserts this was error because an ALJ must consider all impairments, both severe and non-severe, together when determining a claimant's RFC.
We disagree with Martes's reading of the ALJ's decision. The ALJ stated that although she found the impairments mentioned non-severe - as well as a right shoulder injury, and childhood asthma - she had "considered these impairments when drafting the residual functional capacity outlined below." R. 14. In other words, the ALJ omitted additional limitations in Martes's RFC relating to the non-severe impairments because she found that the non-severe impairments did not cause greater limitations than those already included the RFC. In fact, the ALJ extensively discussed Martes's diagnosis of adjustment reaction disorder at step three of his analysis, see R. 13-14, and discussed Martes's treating psychologist Dr. Witt's opinion concerning Martes's functional limitations when weighing the medical evidence relevant to the RFC determination, R. 17. The ALJ, however, concluded that Martes "is mentally capable of performing substantially all unskilled jobs," including by "understanding, carrying out and remembering simple instructions; us[ing] judgment; responding appropriately to supervision, coworkers and usual work situations; and dealing with changes in a routine work setting." R. 13. The ALJ similarly concluded that despite Martes's diagnosis for high blood pressure, "the record supports only routine *769treatment with no symptoms, complications or significant limitations caused by this condition." R. 13. Any elevated readings, the ALJ reasoned, were due to Martes's conceded noncompliance with his medication protocols.
We also note that these conclusions are supported by the record. As to Martes's mental limitations, his therapist's notes show that Martes reported feeling depressed, struggling with sleep and relationships, and feeling lethargic; yet his therapist recommended only therapy, stating that medication was unnecessary and even noting "some improvement" and "mild improvement" after two psychotherapy sessions. R. 358-63. Martes also attended only six psychotherapy sessions over the course of fourteen months,
As to Martes's high blood pressure, Martes told Dr. Rai that he was non-compliant with his blood pressure medication and that his physician had recently directed him to start taking his medication as directed. R. 314. He denied any history of a transient ischemic attack (i.e., a mini-stroke), a stroke, or myocardial infarction. R. 314. Martes likewise denied any recent asthma flare-ups, R. 314, and the record is silent on Martes's shoulder repair. Because substantial evidence supports the ALJ's decision to omit limitations relating to Martes's non-exertional impairments from his RFC, there is no basis on which to remand for further consideration of Martes's non-exertional impairments in the RFC analysis.
E. Application of the Medical-Vocational Guidelines to Martes
Martes argues that the ALJ erred in applying the Medical-Vocational Guidelines (commonly known as "the Grids") because the ALJ did not "cite examples of any occupations that an individual with [his] RFC ... could do," as required according to SSR 96-9p. Pl. Mem. at 12-13. He further contends that the ALJ "should have obtained the testimony of a vocational expert to provide examples of limited sedentary jobs ... that an individual with the ALJ's formulated RFC could do." Id. at 14.
An ALJ is not precluded from exclusively using the Grids. See Merriman v. Comm'r of Soc. Sec.,
*770Zabala v. Astrue,
The ALJ assessed Martes with suffering from the following non-exertional impairments: a restriction to "occasionally climbing, balancing, kneeling, stooping, crouching and crawling" due to his knee and back problems. R. 15. Martes asserts that he also suffers from the following additional non-exertional impairments: "need for a hand-held assistive device," Pl. Mem. at 13, "the effects of [his] non-severe impairments," "the side effects of his medications," and "the non-exertional limitations due to pain as noted by Dr. Witt," id. at 14. With respect to Martes's asserted need for a hand-held assistive device, the ALJ rejected Martes's asserted use of a cane finding that the record did not support it. R. 16. In doing so, she relied on Dr. Rai's opinion that use of a cane was not medically necessary. R. 315. We thus find no error in the ALJ's conclusion that Martes's professed use of a cane did not deprive him of a meaningful employment opportunity. See Suarez v. Colvin,
With respect to Martes's non-exertional limitations, the ALJ concluded that the limitations "have little or no effect on the occupational base of unskilled sedentary work." R. 18. The ALJ relied on SSR 96-9p, which provides that "[p]ostural limitations or restrictions related to such activities as climbing ladders, ropes, or scaffolds, balancing, kneeling, crouching, or crawling would not usually erode the occupational base for a full range of unskilled sedentary work significantly because those activities are not usually required in sedentary work." SSR 96-9p,
Martes argues that the ALJ's finding "runs against Social Security Rulings," Pl. Mem. at 13, citing SSR 96-9p, which states:
"balancing" means maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on narrow, slippery, or erratically moving surfaces. If an individual is limited in balancing only on narrow, slippery, or erratically moving surfaces, this would not, by itself, result in a significant erosion of the unskilled sedentary occupational base. However, if an individual is limited in balancing even when standing or walking on level terrain, there may be a significant erosion of the unskilled sedentary occupational base. It is important to state in the RFC assessment what is meant by limited balancing in order to determine the remaining occupational base. Consultation with a vocational resource may be appropriate in some cases.
Martes argues that the ALJ erred because the ALJ did not "cite examples of any occupations that an individual with [his] RFC ... could do." PL Mem. at 13. In support of his argument, Martes quotes SSR 96-9p, which provides that "the adjudicator must cite examples of occupations or jobs the individual can do and provide a statement of the incidence of such work in the region where the individual resides."
IV. CONCLUSION
For the foregoing reasons, Martes's motion for judgment on the pleadings (Docket# 17) is denied and the Commissioner's motion for judgment on the pleadings (Docket# 19) is granted.
SO ORDERED.
Related
Cite This Page — Counsel Stack
344 F. Supp. 3d 750, Counsel Stack Legal Research, https://law.counselstack.com/opinion/martes-v-commr-of-soc-sec-ilsd-2018.