Source: https://casetext.com/case/va-y-v-berryhill
Timestamp: 2019-04-18 18:46:35+00:00

Document:
VIRGINIA Y., Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
Virginia filed her application for SSDI and for SSI in September 2014, claiming a disability onset date of January 10, 2011. (Administrative Record ("A.R.") 13, 142.) After her claim was denied initially and upon reconsideration, (id. at 96-104, 134-37), Virginia sought and received a hearing before an administrative law judge ("ALJ"), which took place on August 3, 2016, (id. at 38-89). Virginia was represented by counsel at the hearing. (Id. at 13, 41.) On December 14, 2016, the ALJ issued a decision concluding that Virginia is not disabled and therefore not entitled to SSDI or SSI. (Id. at 10-37.) When the Appeals Council denied Virginia's request for review, (id. at 1-6), the ALJ's decision became the final decision of the Commissioner, see Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015). Virginia filed this lawsuit seeking judicial review of the Commissioner's final decision, see 42 U.S.C. § 405(g); (R. 1), and the parties have consented to this court's jurisdiction, see 28 U.S.C. § 636(c); (R. 5).
With an undergraduate degree in child development and a master's degree in early childhood, (A.R. 45), Virginia worked in childcare services from 1978 through the end of 2010, serving as a teacher, coordinator, consultant, and program director, (id. at 247). Virginia worked as an early childhood services program director for the State of Illinois from 2007 to 2010, supervising Illinois's daycare licensing program. (Id. at 47-49, 53-54, 77, 247-48.) From 2003 to 2007, Virginia served as a consultant for the Philadelphia school system, developing early childhood programs and curriculum. (Id. at 76, 247, 249.) Virginia asserts that beginning in January 2011, at the age of 62, her health declined drastically and prevented her from working. (R. 18, Pl.'s Mem. at 2.) During the administrative hearing in August 2016, Virginia presented medical and testimonial evidence in support of her disability claim.
In December 2012 Virginia visited an asthma outpatient clinic and "[h]er course was described as moderate with two admissions in the past year." (Id. at 22.) In April 2014 Virginia's asthma was under control. (Id. at 24-25, 944-47 (noting "normotensive and normal lung findings" with "no rales, rhonchi, or wheezes"), 1006 (noting "asthma stable" and no albuterol required).) May 2016 testing showed that Virginia's asthma "may not be well controlled," (id. at 1051), but she reported no emergency room visits or hospitalizations because of asthma and her risk was "low," (id. at 1052; see also id. at 988, 997, 1001, 1015, 1019).
Finally, Virginia has suffered from hypertension and obesity since at least 2005. (Id. at 826, 986.) Virginia's hypertension has been well-controlled, (id. at 543, 844, 947, 1079, 1421), and she has tried to lose weight, (id. at 24-27, 444, 1127).
Virginia argues that the ALJ erred by: (1) determining that her sleep apnea and meniscus tear were not severe impairments at step two; (2) failing to support the RFC determination with substantial evidence, including by misapplying the treating physician rule, cherry picking, and playing doctor; (3) improperly evaluating her symptoms; and (4) finding that she could perform past relevant work. This court reviews the ALJ's decision only to ensure that it is supported by substantial evidence, meaning "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." See Shideler v. Astrue, 688 F.3d 306, 310 (7th Cir. 2012) (internal quotation and citation omitted). This court's role is neither to reweigh the evidence nor to substitute its judgment for the ALJ's. See Pepper v. Colvin, 712 F.3d 351, 362 (7th Cir. 2013). That said, if the ALJ committed an error of law or "based the decision on serious factual mistakes or omissions," reversal may be required. Beardsley v. Colvin, 758 F.3d 834, 837 (7th Cir. 2014).
Virginia argues that the ALJ erred when he deemed her sleep apnea and meniscus tear non-severe. As the claimant Virginia bears the burden of proving severity at step two. See Castile v. Astrue, 617 F.3d 923, 926 (7th Cir. 2010). "A severe impairment is an impairment or combination of impairments that 'significantly limits [one's] physical or mental ability to do basic work activities.'" Id. (quoting 20 C.F.R. § 404.1520(c)); see also SSR 96-3P, 1996 WL 374181 (July 2, 1996). When determining severity, courts may consider "whether the claimant received a 'definite diagnosis,' whether treatment was recommended, and whether medication remedied or controlled the impairment." Colson v. Colvin, 120 F. Supp. 3d 778, 788 (N.D. Ill. 2015) (internal quotation omitted).
Reviewing the medical records and Virginia's hearing testimony, the court finds that there is substantial evidence to support the ALJ's non-severity finding as to sleep apnea. See Minnick, 775 F.3d at 935. The record refers generally to a previous diagnosis of obstructive sleep apnea, (A.R. 530, 579, 1162, 1253), but lacks any objective evidence that the condition limits Virginia's ability to work in any way, let alone significantly, see 20 C.F.R. § 404.1520(c); see also Colson, 120 F. Supp. 3d at 788. Virginia fails to point to any evidence indicating when she was diagnosed with sleep apnea, the basis for the diagnosis, treatment for the condition, or whether it was remedied. (See R. 18, Pl.'s Mem. at 14-15.) Nor did Virginia complain about sleep apnea during the hearing. (A.R. 16); see also Schloesser v. Berryhill, 870 F.3d 712, 718-19 (7th Cir. 2017) (finding that minimal complaints and treatment support a non-severity finding).
Virginia contends that her testimony that she needed to sleep two to four times per day was sufficient to prove the severity of her sleep apnea. (R. 27, Pl.'s Reply at 2.) But she testified that her drowsiness increased when she took medication. (A.R. 72.) Furthermore, when posing hypothetical questions to the VE during the hearing, Virginia's counsel tied her need for unscheduled breaks to "dozing off from medication." (Id. at 86.) Neither Virginia nor her counsel referred to sleep apnea.
Likewise, the ALJ's non-severity finding as to Virginia's torn meniscus does not amount to a reversible error. The record includes an MRI showing a torn meniscus. (A.R. 1017, 1035-36, 1100.) The ALJ determined that "objective documentation concerning this impairment is not of record." (Id. at 16.) However, the ALJ found that limitations in Virginia's RFC because of osteoarthritis would accommodate a torn meniscus in the same knee. (Id.); see also Golembiewski v. Barnhart, 322 F.3d 912, 918 (7th Cir. 2003) (when assessing an RFC, the ALJ considers the "aggregate effect of the entire constellation of ailments," both severe and non-severe) (emphasis in original). Because the ALJ considered Virginia's osteoarthritis, knee pain, and torn meniscus in assessing the RFC, (A.R. 18-28), "no error could result solely from [the ALJ's] failure to label [the meniscus] impairment as severe," Cotie v. Colvin, No. 14 CV 7314, 2016 WL 5415045, at *10 (N.D. Ill. Sept. 28, 2016) (internal quotation and citation omitted). Accordingly, the court affirms the ALJ's step two analysis.
(1) whether the physician examined the claimant, (2) whether the physician treated the claimant, and if so, the duration of overall treatment and the thoroughness and frequency of examinations, (3) whether other medical evidence supports the physician's opinion, (4) whether the physician's opinion is consistent with the record, and (5) whether the opinion relates to the physician's specialty.
Brown v. Colvin, 845 F.3d 247, 252 (7th Cir. 2016); see also 20 C.F.R. § 404.1527(c). So long as the ALJ articulates his reasons, he "may discount a treating physician's medical opinion if it is inconsistent" with the opinion of a consulting physician. Skarbek v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004).
Virginia has changed modifiable risk factors but still continues to have chest pain requiring nitro every other day. She is still limited in activities due to the chest pain and physical limitations from the left hip arthritis pain. She is medically maximized and still continues to have chest pain.
In determining the amount of weight to give Dr. Steen's opinion, the ALJ considered factors set forth in 20 C.F.R. § 404.1527(c). The ALJ acknowledged that Dr. Steen was a treating cardiac specialist. (A.R. 29.) But then the ALJ noted that Dr. Steen examined Virginia "only a few times prior to providing his opinion." (Id.) Virginia disputes the number of times Dr. Steen saw her, citing six dates from February 3, 2014, through the date of Dr. Steen's opinion, February 3, 2016. (R. 18, Pl.'s Mem. at 17.) The government responds that only three of those records reflect actual visits during which Dr. Steen examined Virginia. (R. 26, Govt.'s Resp. at 5 (citing R. 18, Pl.'s Mem. at 17; A.R. 674-80 (catheterization report), 683 (same), 1252 (Nov. 4, 2015 progress notes)).) Regardless, the number of examinations by Dr. Steen reflected in the medical record is limited. (Id.); see also 20 C.F.R. § 404.1527(c)(2)(i) ("Generally, the longer a treating source has treated you and the more times you have been seen by the treating source, the more weight we will give to the treating source's medical opinion.").
Next the ALJ addressed inconsistencies between Dr. Steen's opinion and the medical evidence. (A.R. 29.) The ALJ pointed out that neither the record nor Dr. Steen's notes support limitations in his opinion. See 20 C.F.R. § 404.1527(c)(3)-(4). For example, Dr. Steen opined that Virginia's legs needed to be elevated during the day. (A.R. 1027.) Yet Dr. Steen's notes and other evidence of record do not support such a limitation. (Id. at 19, 21, 24, 28-29 (noting no record of edema or an order to elevate the legs); see also id. at 324, 352, 355, 446, 492, 508, 540, 566, 575, 581, 807, 850, 938, 1130, 1162, 1308, 1314, 1346 (reporting no edema, swelling, or need to elevate legs).) Furthermore, Virginia did not cite objective evidence supporting her need to elevate her legs. (R. 18, Pl.'s Mem. at 11, 15-17; R. 27, Pl.'s Reply at 3-6); see also Britt v. Berryhill, 889 F.3d 422, 426 (7th Cir. 2018) (declining to find reversible error where the ALJ determined that no objective medical evidence supported a medical source's allegation that a claimant must elevate his leg at work); 20 C.F.R. § 404.1527(c)(4) ("Generally, the more consistent a medical opinion is with the record as a whole, the more weight we will give to that medical opinion.").
Finally, the ALJ found that Dr. Steen's opinion that Virginia met Listing 4.02 was unsupported. (Id. at 29, 1027-29.) Treatment notes did not show that the listing requirements had been satisfied. (Id. at 29.) Additionally, the narrative that Dr. Steen provided on the "conclusory check box" form did not relate to Listing 4.02. (Id.) The ALJ thus was unsure whether Dr. Steen was "familiar with the listing requirements." (Id.) Here Virginia does not even challenge the ALJ's finding that she did not meet or equal a listed impairment. Substantial evidence therefore supports the ALJ's decision to discount Dr. Steen's opinion to the extent that it was not consistent with the record. See McFadden v. Berryhill, 721 Fed. Appx. 501, 505 (7th Cir. 2018); Hall v. Berryhill, ___ Fed. Appx. ___, 2018 WL 4959710, at *3 (7th Cir. Oct. 15, 2018).
Virginia claims that the state agency medical opinions merited little weight because the physicians never examined Virginia, did not review all relevant evidence, and did not hold board certifications. (R. 18, Pl.'s Mem. at 18-19.) Under 20 C.F.R. § 404.1527(e)(2)(i), an ALJ "must consider findings and other opinions of State agency medical and psychological consultants," id. (emphasis in original), and may assign more weight to such physicians than to treating sources in certain situations, SSR 96-6p, 1996 WL 374180, at *3 (July 2, 1996). Thus, even though the state agency physicians did not examine Virginia, the ALJ appropriately relied upon "the opinions of physicians . . . who are also experts in social security disability evaluation." See Flener v. Barnhart, 361 F.3d 442, 448 (7th Cir. 2004). While the state agency physicians did not review all relevant evidence, the ALJ noted that fact and limited the weight he afforded to them accordingly. (A.R. 29-30.) The court finds no reversible error in the ALJ's evaluation of the opinions of Drs. Dow or Madala.
Virginia further contends that the ALJ improperly highlighted normal findings while ignoring contrary findings. (R. 18, Pl.'s Mem. at 17.) She points to records that she alleges the ALJ purposefully omitted: "the abnormal myocardial perfusion study, the abnormal EKG showing sinus bradycardia, the cardiac catheterization demonstrating native [CAD,] and the angiography which showed severe atherosclerosis." (Id.) But an ALJ is not required to discuss every piece of evidence in the record in detail. See Pepper, 712 F.3d at 362. Even so, the ALJ here expressly referred to Virginia's October 20, 2014 cardiac catheterization confirming CAD. (A.R. 24.) A review of the ALJ's 19-page opinion reveals multiple references to Virginia's "long history of cardiac . . . impairments," (id. at 30), including CAD, history of CHF, bypass surgeries, catheterization procedures, angina, shortness of breath, jaw pain, CCS classifications, left atrial enlargement, left ventricular hypertrophy, and other cardiac issues, (id. at 21-24, 28-29). Indeed, in part because of Virginia's cardiac issues, the ALJ limited Virginia's RFC to sedentary work beginning in February 2014. (Id. at 23-24.) The court therefore finds that the ALJ adequately reviewed the record and directly addressed Virginia's evidence.
Virginia also asserts that the ALJ improperly played doctor when he found her sleep apnea and meniscus tear to be non-severe, rejected Dr. Steen's opinion that Virginia's legs needed to be elevated, and noted that no medical records suggested that Virginia's bypass surgery or recovery that occurred after the hearing would be "eventful or delayed." (R. 18, Pl.'s Mem. at 19-20.) As explained above, the ALJ did not commit reversible error in assessing the sufficiency of evidence relating to Virginia's sleep apnea and meniscus tear or in evaluating Dr. Steen's medical opinion. The same is true regarding the ALJ's assessment of the medical evidence relating to Virginia's 2016 bypass surgery and recovery. The ALJ noted that in August 2016 Virginia "had severe disease in three vessels, 90 percent LAD, 100 percent circumflex, and 70 percent RCA," thereby "necessitating surgery." (A.R. 29-30.) Virginia underwent bypass surgery on September 19, 2016, (id. at 1455-56), and by October 12, 2016, Dr. Steen reclassified Virginia as CCS I with "stable" CAD, (id. at 1421). The ALJ did not play doctor here but rather assessed the sufficiency of the medical evidence, and in doing so executed the very task assigned to him. See 20 C.F.R. §§ 404.1545, 404.1546(c), 404.1527(d)(2).
Virginia also asserts that the ALJ improperly evaluated her symptoms by relying upon her ability to perform limited activities, discounting her complaints of fatigue, and mischaracterizing her testimony. (R. 18, Pl.'s Mem. at 21-22.) An ALJ's symptom evaluation is entitled to great deference and a reviewing court may only reverse such an assessment where it is "patently wrong." See Stepp v. Colvin, 795 F.3d 711, 720 (7th Cir. 2015). That is because as a witness to the claimant's testimony, the ALJ is in the best position to evaluate the believability of the claimant's symptom descriptions. Id. An "ALJ's credibility findings need not specify which statements were not credible," and if the evaluation is adequate the court will affirm even when it "also contains a considerable amount of boilerplate language and recitations." Shideler, 688 F.3d at 312. In short, a reviewing court will only disturb an ALJ's evaluation of a claimant's symptom description if it "is unreasonable or unsupported." Getch v. Astrue, 539 F.3d 473, 483 (7th Cir. 2008).
activities such as stair climbing, not sitting, standing or walking, which the claimant reported she was able to do without limitation.
(A.R. 29.) The ALJ also noted other inconsistencies that undermined Virginia's allegations, including her ability to shop and engage in "bike riding, use of the treadmill and water aerobics" and a June 27, 2016 report stating that she had "no problem with adult daily living activities." (Id. at 27, 1225, 1345.) The ALJ further observed that Virginia responded "cogently and appropriately" during the 75-minute hearing. (Id. at 29.) The court finds that the ALJ reasonably explained why Virginia's daily activities were inconsistent with her specific symptom allegations.
Virginia next contends that the ALJ unfairly discounted her subjective complaints of fatigue. (R. 18, Pl.'s Mem. at 21.) She points to cardiac issues, sleep apnea, and the fact that she took up to 18 medications a day for support for her need to nap. (Id.) But the ALJ found no basis to credit Virginia's testimony that she needs to nap several times a day. (A.R. 29, 72.) The ALJ explained that "[s]he did not mention this limitation to her treating physician and she explicitly denied any side effects from medication when asked by a doctor." (Id. at 29; see also id. at 19-20, 23, 24, 28.) In her July 2016 statement to the Commissioner listing her medications, Virginia nowhere alleged fatigue or drowsiness as a side effect. (Id. at 310.) Thus, the ALJ provided specific reasons supported by the record to find Virginia's alleged symptoms inconsistent with the evidence. See Hall, 2018 WL 4959710, at *4.
Finally, Virginia claims that the ALJ mischaracterized her testimony. (R. 18, Pl.'s Mem. at 21-22.) Virginia disputes the alleged "independent" nature of her ability to perform daily activities. (Id. at 21.) But the ALJ quoted "independent" from the medical record in referring to Virginia's previous level of functioning before a 2015 fall. (Id. at 27, 1225; see also id. at 1345.) Virginia asserts that her family had to hire an aide to assist her with daily activities such as dressing, hygiene, and meal preparation. (R. 18, Pl.'s Mem. at 21.) The ALJ considered Virginia's testimony and a statement from the care giver, who is Virginia's cousin. (A.R. 30, 62, 1283.) The ALJ found "no objective evidence" indicating that a care giver was necessary. (Id. at 30.) To the contrary, Virginia's ability to swim up to one hour, (id. at 353, 543), and walk without limitations, (id. at 331, 470, 543), undermined her allegations, according to the ALJ. Accordingly, the ALJ's symptom evaluation was reasonable and supported by substantial evidence. See Getch, 539 F.3d at 483.
Virginia argues that the ALJ lacked substantial evidence to determine that she could perform her past relevant work. (R. 18, Pl.'s Mem. at 22-25.) She contends that the ALJ relied upon a faulty RFC and that the ALJ failed to include in the hypothetical question all limitations in the RFC. (Id. at 22-24.) The court disagrees. The hypothetical questions posed to the VE included the limitations that the ALJ deemed credible. Simila v. Astrue, 573 F.3d 503, 521 (7th Cir. 2009) ("[T]he ALJ is required only to incorporate into [her] hypotheticals those impairments and limitations that [she] accepts as credible.") (internal quotation and citation omitted). The first two hypothetical questions posed to the VE included the limitations set forth in the RFC finding from the onset date through January 31, 2014. (R. 26, Govt.'s Resp. at 14 (citing A.R. 17, 83-84).) In the third hypothetical, the ALJ asked if "that person" in the prior hypotheticals were limited to sedentary work whether the outcome would change. (A.R. 84-85.) The question incorporated the limitations from the prior hypothetical, consistent with the RFC finding for the period after February 1, 2014.
Virginia further complains that the ALJ "rejected" the VE's testimony regarding the impact of more severe limitations on the availability of jobs. (R. 18, Pl.'s Mem. at 24.) Here the ALJ found that Virginia did not experience more severe limitations and did not include them in the RFC. (R. 26, Govt.'s Resp. at 14.) As a result, the ALJ was not required to consider how those more severe limitations affected the availability of jobs. The court finds no reason to remand on this issue.
For the foregoing reasons, Virginia's motion for summary judgment is denied, the government's is granted, and the Commissioner's final decision is affirmed.

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