United States District Court, D. Maryland
REPORT AND RECOMMENDATIONS
STEPHANIE A. GALLAGHER, Magistrate Judge.
Pursuant to Standing Order 2013-06, the above-referenced case was referred to me to review the parties' cross-motions for summary judgment and to make recommendations pursuant to 28 U.S.C. § 636(b)(1)(B) and Local Rule 301.5(b)(ix). I have considered the parties' motions and the Plaintiff's reply. ECF Nos. 13, 15, 16. This Court must uphold the Commissioner's decision if it is supported by substantial evidence and if proper legal standards were employed. 42 U.S.C. § 405(g); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). I find that no hearing is necessary. Local R. 105.6 (D. Md. 2011). For the reasons set forth below, I recommend that the Commissioner's motion be granted and the Plaintiff's motion be denied.
Mr. Scott applied for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") on August 13, 2009, alleging a disability onset date of April 1, 2005. (Tr. 265-70). At the hearing, Mr. Scott amended his onset date to August 1, 2009. (Tr. 53-54). His claims were denied initially on January 11, 2010, and on reconsideration on September 21, 2010. (Tr. 155-62, 170-76). An Administrative Law Judge ("ALJ") held a hearing on October 12, 2011, (Tr. 45-106), and subsequently denied benefits to Mr. Scott in a written opinion. (Tr. 18-30). The Appeals Council declined review, (Tr. 1-6), making the ALJ's decision the final, reviewable decision of the agency.
The ALJ found that Mr. Scott suffered from the severe impairments of status post lumbar fusion during 1997, obesity, right hand numbness post injury, and depression. (Tr. 21). Despite these impairments, the ALJ determined that Mr. Scott retained the residual functional capacity ("RFC") to:
perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except that the claimant could occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, stand and/or walk for 6 hours and sit for about 6 hours in an 8hour workday. The claimant could occasionally climb ramps or stairs, balance, stoop, kneel, crouch and crawl. The claimant should never climb ladders, ropes or scaffolds. Handling, fingering and feeling with the dominant right hand should be frequent as opposed to constant. He should avoid concentrated exposure to hazards, dusts, odors, gasses, poor ventilation and temperature extremes. He should have simple, unskilled work, work that is essentially isolated with only occasional supervision. In general, he should have only occasional contact with co-workers. The claimant can perform low stress work, defined as only occasional changes in the work setting, and work not a production pace, meaning paid by the piece or on a production line.
(Tr. 23). After considering testimony from a vocational expert ("VE"), the ALJ determined that Mr. Scott was capable of performing jobs that exist in significant numbers in the national economy, and that he was not therefore disabled. (Tr. 29-30).
Mr. Scott raises three arguments on appeal. First, he argues that the ALJ failed to assign proper weight to the opinions of several sources. Second, he disagrees with the ALJ's analysis of his mental impairments. Finally, he contends that the ALJ erred by denying his request for an in-person hearing. Each argument lacks merit and is addressed sequentially.
Mr. Scott first argues that the ALJ improperly rejected the opinions of three medical sources-Dr. Theodoru, a neurologist, Dr. Gill, a psychiatrist, and Amanda Glenn, a licensed clinical social worker. All three sources treated Mr. Scott at some point, and each provided opinions on his ability to work. The ALJ must generally give more weight to a treating source's opinion. See 20 C.F.R. § 404.1527(c)(2). However, where a treating source's opinion is not supported by clinical evidence or is inconsistent with other substantial evidence, it should be accorded significantly less weight. Craig, 76 F.3d at 590. The ALJ is not required to give controlling weight to a treating source's opinion on the ultimate issue of disability. SSR 96-5p, 1996 WL 374193, at *5 (July 2, 1986). If the ALJ does not give a treating source's opinion controlling weight, the ALJ will assign weight after applying several factors, such as, the length and nature of the treatment relationship, the degree to which the opinion is supported by the record as a whole, and any other factors that support or contradict the opinion. 20 C.F.R. §§ 404.1527(c)(1)-(6); 416.927(c)(1)-(6). Pursuant to Social Security regulations, the ALJ is required to "give good reasons" for the weight assigned to a treating source's opinion. 20 C.F.R. §§ 404.1527(c)(2); 416.927(c)(2).
I find that the ALJ's assignment of no weight to the opinions contained in Dr. Theodoru's March 3, 2011 Medical Source Statement is supported by substantial evidence. The ALJ reasoned that the Medical Source Statement was not supported by the longitudinal medical record. (Tr. 28). The ALJ also stated that the opinions of Dr. Theodoru were "conclusory, " "based on the claimant's subjective complaints, " and were "outside of his range of expertise as Dr. Theodoru's specialty is Internal Medicine and he retains no specialization in Neurology, Psychiatry or Orthopedics." Id. Dr. Theodoru opined that Mr. Scott's low back pain and sarcoidosis allowed him to sit, stand, or walk between 0-2 hours per day, and that Mr. Scott could never lift 20 or 50 pounds. (Tr. 1098). Dr. Theodoru also noted that while Mr. Scott was capable of low stress, his psychological limitations affected his ability to work at a regular job on a sustained basis. (Tr. 1099-1100).
Several records contradict Dr. Theodoru's conclusions. A Physical RFC Assessment by Dr. Najar, a state agency medical consultant, opined that Mr. Scott was capable of lifting 20 pounds occasionally, 10 pounds frequently, and sitting, standing, or walking about 6 hours in an 8 hour workday. (Tr. 1007). The ALJ accorded Dr. Najar's opinions great weight because she found that they, unlike the opinions of Dr. Theodoru, were supported by the medical evidence of record. (Tr. 26). The ALJ pointed to records that demonstrated that Mr. Scott's lower back pain was not disabling. See (Tr. 25, 998-99) (citing normal gait and station, no swelling or deformity in the lower lumbar region, and moderate tenderness at L4 and L5 lumbar vertebrae). Other evidence of record also supports the ALJ's conclusions. See (Tr. 1271-77) (describing low back and knee pain as "stable" and recommending exercise and stretching); (Tr. 1284) (stating that "back pain OK with current meds"). While it would be possible to cite evidence from Mr. Scott's medical record that supports some of Dr. Theodoru's recommended limitations, see (Tr. 1014-15), it is not the role of this Court to weigh conflicting evidence, determine credibility, or substitute its judgment for that of the Commissioner's. See Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Moreover, as noted above, the ALJ has the discretion to accord a treating source's opinion less than controlling weight.
Mr. Scott argues further that the "opinion" of disability by Dr. Prafull K. Dave,  a neurologist, comports with Dr. Theodoru's findings, and that the ALJ committed error by failing to discuss or assign weight to Dr. Prafull's opinion. Pl.'s Mot. 11; Pl.'s Reply 2-3. Mr. Scott is incorrect on both points. First, Dr. Prafull never provided an independent opinion of Mr. Scott's ability to work. In a Medical Evaluation Report dated February 17, 2010, Dr. Prafull described Mr. Scott's subjective complaints, which included "snoring heavily, " "feel[ing] very sleepy during the daytime, " and "doz[ing] off while waiting on the red light." (Tr. 1014). In the sentence that immediately followed the narrative of subjective complaints, Dr. Prafull stated that, "[c]urrently, the patient is disabled." Id. When read in context, it is apparent that Dr. Prafull was merely restating information that Mr. Scott conveyed. Furthermore, Dr. Prafull's findings were unremarkable and at odds with a finding of disability. Dr. Prafull noted that Mr. Scott was "conscious, alert, and oriented to time, place, and persons." Mr. Scott had normal higher cortical function, normal cranial nerves from II to XII, normal coordination of limbs, and no speech and language abnormalities. (Tr. 1015). The only neurological issue that Dr. Prafull noted was short-term memory impairment. Id. Second, the ALJ did discuss Dr. Prafull's report in the opinion. See (Tr. 25). She properly did not characterize the report as an opinion, nor did she assign it weight, because it is evident from context that it is not an opinion.
Substantial evidence also supports the ALJ's assignment of weight to the opinions of Dr. Gill and Ms. Glenn. The ALJ recognized Dr. Gill as a treating medical source, but rejected his opinions because they were "not supported by his own medical records, " "conclusory, " and "primarily based on the claimant's subjective complaints." (Tr. 28). The ALJ noted that Mr. Scott's records, which contained Global Assessment of Functioning ("GAF") scores of 55 and 60, demonstrated "only moderate psychological symptomology, " which was at odds with Dr. Gill's opinions. Id.
I find insufficient support for the ALJ's speculative contention that Dr. Gill's records were based primarily on Mr. Scott's subjective complaints. However, I do find that Dr. Gill's records are inconsistent and contrary to Mr. Scott's overall mental health evidence. The ALJ pointed to three of Dr. Gill's records - a February 22, 2010 Mental Capacities Evaluation, an April 15, 2010 Medical Source Statement, and a February 23, 2011 Medical Source Statement. All three records indicated that Mr. Scott exhibited symptoms such as "difficulty thinking or concentrating, " "paranoid thinking or inappropriate suspiciousness, " and "mood disturbance." (Tr. 1018, 1036, 1247). With respect to functional limitations, all three records similarly noted no restriction of activities of daily living, marked difficulties in maintaining concentration, persistence, or pace, and between one and three episodes of decompensation. (Tr. 1018, 1039, 1249). The records also consistently assessed GAF scores between 55 and 60. (Tr. 1018, 1035, 1246). However, the two Medical Source Statements differed significantly in their conclusions regarding Mr. Scott's mental abilities and the aptitude needed to perform work. The 2011 Medical Source Statement indicated that Mr. Scott was "seriously limited, but not precluded" in all categories. See (Tr. 1248-49). The Medical Source Statement from April, 2010 noted that, in many categories, Mr. Scott had "limited but satisfactory" mental abilities and aptitude to perform work, while in other categories such as "accept[ing] instructions and respond[ing] appropriately to criticism from supervisors, " Mr. Scott was "unable to meet competitive standards." (Tr. 1037-38).
Some of Dr. Gill's conclusions are also at odds with evidence in Mr. Scott's medical record. Dr. Polizos, a state agency medical consultant, completed a Mental RFC Assessment and a Psychiatric Review Technique, both of which failed to corroborate the severe limitations opined by Dr. Gill. Dr. Polizos found no marked limitations in understanding and memory, sustained concentration and persistence, social interaction, and adaptation. See (Tr. 1001-02). Dr. Polizos also concluded that the evidence in Mr. Scott's file demonstrated an ability to "understand remember and execute instructions...respond relate and adopt at work place...and perform simple routine tasks." Id. at 1003. In a Psychiatric Review Technique dated January 4, 2010, Dr. Polizos opined that Mr. Scott had mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence or pace, and no episodes of decompensation, each of extended duration. (Tr. 1030). The ALJ further noted that Dr. Polizos's opinions in the Psychiatric Review Technique were affirmed upon reconsideration by Gemma Nachbahr, a state agency psychological consultant. See (Tr. 27, 1093). A Consultative Evaluation Report by Dr. Kradel noted relatively normal mental status, and the ALJ highlighted the fact that Mr. Scott coaches athletic games. See (Tr. 989-92) (stating no signs of ...