Court Opinion

ID: 623544
Source: CourtListenerOpinion
Date Created: 2012-02-25 01:01:44+00
Date Added: 2024-06-11T17:51:04.618565
License: Public Domain

NOT PRECEDENTIAL

                      UNITED STATES COURT OF APPEALS
                           FOR THE THIRD CIRCUIT
                                ___________

                                    No. 11-2499
                                    ___________

                           GREGORY SCOTT SCHMIDT,
                                            Appellant

                                          v.

                      COMMISSIONER SOCIAL SECURITY

                             _______________________

                   On Appeal from the United States District Court
                       for the Middle District of Pennsylvania
                         D.C. Civil Action No. 10-cv-02271
                             (Honorable Malcolm Muir)
                                  ______________

                   Submitted Pursuant to Third Circuit LAR 34.1(a)
                                  January 9, 2012

              Before: SCIRICA, RENDELL and SMITH, Circuit Judges.

                              (Filed: February 24, 2012)

                                 _________________

                             OPINION OF THE COURT
                                _________________

SCIRICA, Circuit Judge.

      Gregory Scott Schmidt appeals from the District Court’s order affirming the

decision of an Administrative Law Judge (“ALJ”) to deny Schmidt’s claims for
Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under

42 U.S.C. §§ 401 et seq. and 1381-1383f. We will affirm. 1

                                           I.

      From January 2006 through November 9, 2007, Schmidt worked as a truck driver

and heavy equipment operator. He injured his back while working on November 9, 2007,

and filed a timely workers’ compensation claim.

      Schmidt was first evaluated by orthopedic surgeon Dr. Pandelidis on November

29, 2007. Dr. Pandelidis noted Schmidt’s x-rays showed moderate disc degeneration and

mild lumbar degeneration. A subsequent lumbar MRI confirmed an L4-5 disc herniation

with stenosis. On December 28, 2007, Schmidt underwent an L4-5 disc excision; three

weeks later, Dr. Pandelidis noted Schmidt was improving but was unable to return to his

previous job.

      In the months following the surgery, Dr. Pandelidis reported Schmidt was

recovering well and his symptoms were improving. On April 4, 2008, Dr. Pandelidis

authorized Schmidt to return to restricted work duties. On August 6, 2008, Schmidt saw

pain specialist Dr. Gilhool, who recommended epidural steroid injections which

temporarily helped to resolve Schmidt’s back pain.

      In May 2009, Schmidt again complained of severe ongoing back pain. Dr.

Pandelidis recommended intermittent pain medication and an exercise program to relieve

Schmidt’s pain. On May 22, 2009, Dr. Pandelidis completed a Department of Public

1
  The District Court had jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3). We have
jurisdiction under 28 U.S.C. § 1291.
                                           2
Welfare (“DPW”) form that labeled Schmidt as “permanently disabled.” During the

following five months, Dr. Gilhool repeatedly recommended conservative care consisting

of pain medication and exercise.

       On December 8, 2008, Schmidt filed an application for DIB, alleging he was

disabled as of November 9, 2007. On December 23, 2008, he filed an application for

SSI. The ALJ conducted a hearing on March 10, 2010, and issued a decision denying

disability benefits on May 14, 2010. The ALJ found Schmidt had severe impairments,

but none that required an automatic determination of disability. The ALJ concluded

Schmidt had the residual functional capacity (“RFC”) to perform sedentary work. 2

Schmidt requested review by the Appeals Council and submitted supplemental evidence

including a December 2009 x-ray which showed some disc degeneration, but no fractures

or instability, and a 2010 MRI which revealed new degeneration at L3-4 and L4-5, but no

significant nerve compression. The Appeals Council found no basis to alter the ALJ’s

decision, thus making the ALJ’s decision final.

       Schmidt then commenced a civil action in the District Court, contending the denial

of his claims was not supported by substantial evidence. On May 6, 2011, the District

Court affirmed the ALJ’s decision and entered judgment in the Commissioner’s favor.

This timely appeal followed.

                                             II.

2
  Sedentary work involves lifting no more than ten pounds at a time and occasionally
lifting or carrying articles like docket files, ledgers, and small tools. A certain amount of
walking or standing is often necessary. 20 C.F.R. §§ 404.1567(a), 416.967(a).
                                              3
       Our review is limited to determining whether the ALJ’s decision was supported by

substantial evidence. Richardson v. Perales, 402 U.S. 389, 390 (1971); Brown v. Astrue,

649 F.3d 193, 195 (3d Cir. 2011). Substantial evidence is defined as “more than a mere

scintilla;” it means “such relevant evidence as a reasonable mind might accept as

adequate.” Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999) (quoting Ventura v.

Shalala, 55 F.3d 900, 901 (3d Cir. 1995)). An appellate court is not permitted to reweigh

the evidence. Williams v. Sullivan, 970 F.2d 1178, 1182 (3d Cir. 1992).

                                            III.

                                            A.

       Schmidt contends the ALJ erred in finding he has the RFC to perform sedentary

work. To determine whether a claimant is disabled, the Commissioner considers, in

sequence, whether a claimant (1) is engaged in substantial gainful activity; (2) has a

severe impairment; (3) has an impairment that meets the list of impairments in the

regulations; (4) can return to his past relevant work; and (5) is capable of performing

other work in the national economy. 20 C.F.R. §§ 404.1520, 416.920; Brewster v.

Heckler, 786 F.2d 581, 583-84 (3d Cir. 1986). At the fifth step, the ALJ may find the

claimant has RFC based on all relevant evidence. 20 C.F.R. §§ 404.1545, 416.946. A

claimant’s RFC is an assessment of the claimant’s ability to work for a maximum of eight

hours per day, five days per week. SSR 96-8p.

                    1. ALJ’s Finding of RFC for Sedentary Work

       The ALJ concluded Schmidt had the RFC to perform sedentary work, and the

medical records “[did] not show signs, symptoms or functional limitations consistent with

                                             4
the claimant’s allegations of disabling severity.” We agree with the District Court that

the ALJ’s determination was supported by substantial evidence.

       Schmidt’s medical records reveal that, following his 2007 surgery, he experienced

significant relief from his back pain. In April 2008, Dr. Pandelidis noted Schmidt was

capable of working with some physical restrictions, and Dr. Gilhool noted a spinal MRI

showed no herniation or hematoma. Further, Dr. Gilhool’s progress reports from August

2008 through November 2009 consistently reported Schmidt was able to ambulate and

perform activities of daily living without assistance. In May 2009, Dr. Pandelidis noted

Schmidt could work with restrictions. Similarly, Schmidt’s family physician, Dr. Davis,

wrote on May 15, 2009 that Schmidt “may be able to do some kind of work.” Physical

examinations revealed he had no motor loss, lower extremity atrophy, or serious gait

impairment.

       Although Schmidt argues the ALJ failed to consider supplementary December

2009 and January 2010 diagnostic tests, that evidence does not upset the District Court’s

finding that the ALJ’s decision was based on substantial evidence. Schmidt’s December

2009 x-ray showed some disc degeneration, but no fractures or instability. 3 Schmidt’s

2010 MRI revealed some degeneration at L3-4 and L4-5, but no significant nerve

compression. Following the 2010 MRI, Dr. Pandelidis recommended conservative care

3
  Schmidt points to a December 23, 2009 report in which Dr. Gilhool noted Schmidt was
not able to ambulate and perform activities of daily living without a cane. The ALJ
considered Schmidt’s use of a cane for ambulation, but noted there was no indication that
it was medically prescribed. To the extent there is any doubt as to whether this is
evidence of disabling severity, that doubt is not dispositive, because the question is not
whether evidence supports the claimant’s allegation of disability, but rather whether there
is substantial evidence that supports the ALJ’s finding.
                                             5
including “intermittent medications and exercises.” The results of these tests were taken

into consideration by the ALJ, but “did not show any serious abnormalities . . . despite

[Schmidt’s] ongoing complaints.”

       Based on the record, Schmidt was able to perform daily functions without

assistance, was cleared for work with restrictions, was prescribed only conservative care,

and suffered no significant clinical impairments subsequent to his 2007 surgery. We

agree with the District Court that the ALJ’s decision to find RFC for sedentary work was

supported by substantial evidence.

                     2. Weight Given to Dr. Pandelidis’s Opinion

       Schmidt argues the ALJ erred in refusing to give controlling weight to the opinion

of Dr. Pandelidis. Dr. Pandelidis’s opinion evidence consisted of a DPW form indicating

Schmidt was “permanently disabled” as of May 22, 2009. 4

       The Commissioner retains sole decision-making authority to determine whether a

claimant is disabled. 20 C.F.R. §§ 404.1527(e)(2), 416.927(e)(2). In order to give

significant weight to a physician’s opinion, the ALJ must consider the opinion’s

supportability and consistency with the record as a whole. SSR 96-5p. The ALJ “may

4
  At the ALJ hearing, Schmidt objected to the admission of a second DPW form,
completed by Dr. Pandelidis, dated May 11, 2009. On this form, Dr. Pandelidis checked
“employable” and explained that Schmidt was “unable to do any job that involves
frequent bending, lifting, twisting or lifting greater than 20 pounds.” This mirrors the
findings in Dr. Pandelidis’s May 2009 progress report. However, the ALJ neither
admitted the May 11 form into evidence, nor relied on the form in his decision. Because
there is other substantial evidence to support the ALJ’s finding, we need not consider the
probative value of this form.
                                             6
reject a treating physician’s opinion outright only on the basis of contradictory medical

evidence.” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000).

       First, Dr. Pandelidis’s DPW opinion consisted largely of checked boxes on a

standard DPW form. We have previously found the credibility of this type of opinion

evidence to be open to question. See Mason v. Shalala, 994 F.2d 1058, 1065 (3d Cir.

1993) (“[F]orm reports in which a physician’s obligation is only to check a box or fill in a

blank are weak evidence at best.”). As the ALJ noted, the DPW form was completed in

order to obtain public assistance and did not provide any clinical findings to support Dr.

Pandelidis’s opinion. See 20 C.F.R. §§ 404.1527(d)(3), 416.927(d)(3) (explaining more

weight is given to opinions that include objective medical evidence). Dr. Pandelidis

wrote only “low back pain, lumbar disc degeneration,” but failed to provide any medical

findings to support his opinion.

       Second, the record contains medical evidence contrary to Dr. Pandelidis’s opinion.

Dr. Pandelidis himself noted in a May 2009 progress report—the same month that he

submitted the DPW form—that Schmidt “should try to avoid heavy lifting at work,” “he

should not do any job that involves frequent bending, . . . twisting or lifting greater than

20 pounds,” and that “[h]e may be a good candidate for occupational vocational

rehabilitation.” In January 2010, Dr. Pandelidis noted Schmidt would be best treated

only with medication and strengthening exercises.

       Schmidt’s other physicians disagreed with Dr. Pandelidis’s DPW opinion. From

August 2008 through November 2009, Dr. Gilhool noted Schmidt was able to ambulate

and perform activities of daily living without assistance. In May 2009, the same month

                                              7
in which Dr. Pandelidis completed the DPW form, Dr. Davis noted Schmidt “may be able

to do some kind of work.” Following his 2007 back surgery, Schmidt’s physicians

repeatedly recommended conservative treatment for his back pain. Thus, medical

evidence in the record contradicts Dr. Pandelidis’s opinion, and we find substantial

evidence supports the ALJ’s decision to reject Dr. Pandelidis’s opinion.

                                            B.

       Schmidt next contends the ALJ failed to properly consider his subjective

complaints of pain in adjudicating his disability claim. To determine whether a claimant

is disabled, the Commissioner considers “all. . . symptoms, including pain, and the extent

to which [these] symptoms can reasonably be accepted as consistent with the objective

medical evidence.” 20 C.F.R. §§ 404.1529(a), 416.929(a). Pain alone will not establish

disability. Id. The ALJ must follow a two-step process for evaluating pain: first, whether

there is a medical impairment that could reasonably be expected to produce the pain; and

second, an evaluation of the symptoms to determine if they limit the claimant’s ability to

work. SSR 96-7p. Allegations of pain must be consistent with objective medical

evidence, and the ALJ must explain the reason for rejecting non-medical testimony.

Burnett v. Comm’r of Social Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000).

       The ALJ’s conclusion that Schmidt’s subjective complaints of pain were not

disabling is supported by substantial evidence. The ALJ satisfied the two-part test

required in the regulations, concluding the pain could be caused by the claimant’s

medical impairments, but the intensity, persistence, and limiting effects of the pain were

                                             8
inconsistent with objective medical evidence. After review of the record, it is clear the

objective medical evidence supports the ALJ’s conclusion.

       In 2007, Schmidt underwent back surgery, after which he improved from a

symptomatic and clinical standpoint. On April 4, 2008, Schmidt was cleared to return to

work with restrictions. Even after that date, there was objective medical evidence that

did not support Schmidt’s subjective complaints of disabling pain. For example, Schmidt

was able to perform activities of daily living without assistance from August 2008

through November 2009. Despite complaints of increased pain, Schmidt’s December

2009 x-ray showed no abnormalities. Dr. Gilhool, a pain management specialist, noted a

2010 MRI showed no significant nerve compression. Both Dr. Gilhool and Dr.

Pandelidis continued to prescribe conservative care throughout this period. These records

are inconsistent with Schmidt’s allegation of disabling pain.

       Schmidt complained of severe back pain in his testimony at the ALJ hearing and at

several points throughout his medical history. But the ALJ considered Schmidt’s

symptoms and ultimately decided that “there were no worsening clinical findings to

support why he is now more limited” than the period following his 2007 back surgery,

emphasizing he was able to perform daily living activities. The ALJ explained his

reasons for discrediting Schmidt’s subjective testimony and pointed to several objective

medical findings that contradicted Schmidt’s subjective complaints. 5 Because there is

5
 Schmidt’s assertion that the ALJ found no contrary medical evidence to rebut his claim
of pain is inaccurate. The ALJ devoted nearly four pages to discussing Schmidt’s pain
and the objective medical evidence that contradicted his symptoms.
                                             9
substantial evidence to support the ALJ’s conclusion that Schmidt’s pain was not

disabling, the District Court did not err in affirming the ALJ’s decision.

                                             C.

       Finally, Schmidt contends the ALJ failed to properly consider the deleterious

effects of medication on his ability to work. The effect of medication on a claimant’s

ability to work will be considered if it “can reasonably be accepted as consistent with the

objective medical evidence.” 20 C.F.R. § 404.1529(c)(3). Factors that will be considered

include the “type, dosage, effectiveness, and side effects” of any medication. Id. §

404.1529(c)(3)(iv). When assessing the credibility of a claimant’s testimony, the

adjudicator must consider any subjective effects of medication. SSR 96-7p.

       The ALJ did not explicitly address the possible effects of Schmidt’s current

medication in his decision to deny disability benefits. The District Court noted this

omission, but found it to be “harmless error,” following Box v. Astrue. 2010 WL 129773

at *5-8 (C.D.Ca. 2010). 6 Reasoning (1) the record did not contain complaints by Schmidt

to his physicians about the medications, (2) side effects were considered when

prohibiting him from operating heavy equipment, and (3) physicians did not indicate

medication would preclude him from working, the District Court affirmed the ALJ’s

6
  Box relies on Ninth Circuit case law that finds harmless error where the ALJ did not
discuss medication side effects because plaintiff “failed to present the issue below and
there were only passing references to medication side effects that were never the basis of
any claim of inability to work or mentioned by any of the treating and examining medical
sources.” Box, 2010 WL 129773 at *7.

                                             10
determination. Schmidt v. Comm’r of Social Sec. Admin., No. 4:10-CV-02271 (M.D.Pa.

May 6, 2011).

       We have previously held where the ALJ fails to provide “any explanation for his

implicit rejection of [the claimant’s] testimony regarding the effects of the medication he

took,” it is unclear whether such testimony is “not credited or simply ignored.” Stewart

v. Secretary of Health, Educ. and Welfare of U.S., 714 F.2d 287, 290 (3d Cir. 1983). The

ALJ is required to include reasoning for rejecting any relevant evidence, and where no

reasoning is provided, we generally remand for the ALJ to consider the impact of the

medication side effects on the claimant’s disability status. Id.

       Schmidt’s case does not require us to remand. The ALJ discussed Schmidt’s

mental status, found he did not suffer from any serious mental limitations, and

determined he had no difficulty with memory or concentration. Schmidt points to Dr.

Davis’s May 15, 2009 notation that “it really would not be safe working anyway with the

medications that he is currently taking,” and to his own testimony at the ALJ hearing

regarding side effects. Dr. Davis’s note is unpersuasive because at the time of the

hearing, Schmidt was taking different medications and had ceased taking narcotics

altogether. Schmidt’s own testimony is likewise unavailing because when asked what

side effects he was experiencing, he answered, “They’ll give you the side effects of being

dizzy or being very sleepy . . . . you can lose your concentration” and “[the labels]

specify not to drive or operate machinery.” His answers indicate possible side effects,

not side effects he personally experienced.

                                              11
       Even if we were to remand, there is no evidence that would lead the ALJ to

change his assessment of Schmidt’s disability status. Schmidt testified the Office of

Vocational Rehabilitation expressed doubt as to how he “would work if [he’s] on those

types of medications.” But failure to consider side effects is not error where the only

probative evidence is the claimant’s own conclusory statements. The alleged effects of

Schmidt’s medication are not consistent with the medical evidence in the record.

Because there is substantial evidence to support the ALJ’s conclusion that Schmidt did

not experience disabling side effects from his medication, the District Court did not err in

affirming the ALJ’s decision.

                                                 IV.

       For the foregoing reasons, we will affirm the judgment of the District Court.

                                            12