Court Opinion

ID: 4174392
Source: CourtListenerOpinion
Date Created: 2017-06-05 19:04:53.563747+00
Date Added: 2024-06-11T14:13:00.382143
License: Public Domain

Case: 16-11837   Date Filed: 06/05/2017   Page: 1 of 20

                                                     [DO NOT PUBLISH]

           IN THE UNITED STATES COURT OF APPEALS

                   FOR THE ELEVENTH CIRCUIT
                     ________________________

                           No. 16-11837
                       Non-Argument Calendar
                     ________________________

                  D.C. Docket No. 9:14-cv-81398-BB

LAUREN J. HOROWITZ,

                                             Plaintiff - Appellant,

                                versus

COMMISSIONER OF SOCIAL SECURITY,

                                             Defendant - Appellee.

                     ________________________

              Appeal from the United States District Court
                  for the Southern District of Florida
                    ________________________

                            (June 5, 2017)
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Before TJOFLAT, WILLIAM PRYOR and JILL PRYOR, Circuit Judges.

PER CURIAM:

      Lauren Horowitz appeals the district court’s order affirming the

Commissioner of Social Security’s decision denying her application for disability

insurance benefits. On appeal, she argues that the Commissioner’s denial of

benefits was erroneous because the administrative law judge (“ALJ”) improperly

assigned little weight to the opinions of her treating psychologist and determined

that her testimony about the intensity, persistence, and limiting effect of her

symptoms was not credible. She also argues that the Appeals Council improperly

denied review and refused to consider additional evidence that she submitted for

the first time to the Appeals Council. After careful consideration, we affirm the

district court’s judgment in favor of the Commissioner.

                         I.     FACTUAL BACKGROUND

      Horowitz filed for disability benefits, alleging that she became disabled as of

December 2011, on the basis that she suffered from numerous mental and physical

impairments, including post-traumatic stress disorder, depression, obsessive

compulsive disorder, anxiety, and fibromyalgia. She requested and received a

hearing before an ALJ.

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A.    The ALJ Hearing

      At the hearing, Horowitz testified that she was no longer able to work

because of her physical and mental impairments. With respect to her physical

condition, she testified that she suffered from fibromyalgia. She described how

she experienced pain throughout her body including in her jaw, neck, back, and

shoulders. She also testified that she was further injured when she was abducted

and held hostage for two months. She claimed that her right leg was injured in the

abduction and that as a result she needed a cane to walk. She also stated that she

suffered from other physical ailments including migraines, hyperhidrosis

(excessive sweating), and irritable bowel syndrome. She also testified that she was

unable to sleep, had restless sleep, or experienced too much sleep. With respect to

her mental condition, she asserted that her depression left her unable to leave her

home. She also explained that she had trouble concentrating and remembering

things and heard noises other people could not hear.

      Horowitz described how her injuries impacted her daily life. She explained

that she spent most days in bed watching television. Several days a week, she was

unable to get out of bed because of the pain, and about two days a week she was

unable to walk. She testified that she bathed infrequently, ate only frozen food to

avoid cooking, depended on family to do her laundry, and was unable to do chores

around her house. Horowitz stated that her only hobby was playing with her cat.

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She further claimed that as a result of her injuries she could lift no more than five

pounds, stand for only ten minutes at a time, and sit for only ten minutes at a time.

      Horowitz also presented medical evidence to the ALJ. The medical records

about her physical condition reflected that she had suffered from fibromyalgia and

pain since 2005, as well as hyperhidrosis. Horowitz claimed that she was disabled

as of December 2011, but the medical evidence reflected that she received no

treatment for her physical injuries from December 2011 until September 2013.

There were records of medical examinations by non-treating physicians during this

time who examined Horowitz to determine whether she was disabled.

      One of these examinations was performed by Dr. Nader Daryace in

December 2012. Dr. Daryace noted that Horowitz was complaining of pain in her

neck and lower back but experienced no weakness or numbness. Horowitz told Dr.

Daryace that she was able to do her own grocery shopping, cooking, cleaning,

laundry, and gardening. Dr. Daryace’s examination showed that Horowitz had a

full range of motion except in her cervical spine, a normal gait, normal reflexes,

and 5/5 grip strength.

      About three months later, Dr. Steven Kanner examined Horowitz in

connection with her disability application. Dr. Kanner noted that Horowitz

reported that she suffered from arthritis and was in pain all the time. She

complained about neck and back pain, claiming that her back pain sometimes

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radiated down her right leg. Horowitz further reported that she could only sit or

stand for 15 minutes before the pain worsened. In his examination, Dr. Kanner

observed that Horowitz had multiple tender trigger points and a decreased range of

motion of her cervical and thoracolumbar spine. After observing that she had no

motor reflex deficits and ambulated easily and without assistive devices, he opined

that she could sit, stand, and walk without difficulty. He further noted that she had

extensive psychiatric issues.

      Several months later, in September 2013, Horowitz was treated by Dr.

Howard Busch, a rheumatologist. Horowitz was referred to Dr. Busch by another

physician for evaluation of her pain. Dr. Busch’s notes show that Horowitz

complained to him about pain in her joints and neck as well as leg cramps and

achiness. Dr. Busch noted that he believed that her problems were not caused by

arthritis and that her sleep disturbances were contributing to her pain and fatigue.

He indicated that further investigation was required to differentiate or demonstrate

illness. Dr. Busch recommended that Horowitz undergo several laboratory tests.

He also prescribed medication for Horowitz’s pain and to help her sleep.

      About a month later, Horowitz returned to Dr. Busch for a follow-up visit.

He noted that her laboratory test came back essentially normal. Because she

continued to experience pain, he prescribed her a narcotic and additional

medication to help her sleep. Although Dr. Busch recommended that Horowitz

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return for a follow up appointment in a few weeks, there are no other medical

records reflecting treatment from Dr. Busch.

      With regard to her mental condition, Horowitz presented medical records for

treatment she received from the Jerome Golden Center for Behavior Health. These

records show that Dr. Sultana, a psychiatrist, treated her in five appointments over

the course of five months. Dr. Sultana diagnosed Horowitz with post-traumatic

stress disorder, a mood disorder, opioid disorder, and benzodiazepine dependence.

Dr. Sultana’s records reflect that each appointment was for medication

management and lasted only 15 minutes. Dr. Sultana’s treatment notes reflect that

Horowitz reported experiencing anxiety, anger, flashbacks, and nightmares and

that she was pulling out her eyelashes. Her notes also indicated that after a few

appointments Horowitz’s affect and mood improved.

      While treating Horowitz, Dr. Sultana completed a Treating Source Mental

Status Report. In the report, Dr. Sultana described Horowitz as having a depressed

mood and affect but found that her thought process was goal-directed; her

concentration was fair; and she was oriented to time, place, and persons. But at the

end of the report, Dr. Sultana opined that Horowitz’s memory and concertation

was impaired. She also stated that Horowitz was incapable of sustaining work

activity for eight hours a day. Although the report asked Dr. Sultana to provided

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examples of behavioral objective data that supported her opinion, she cited no such

data.

        Other records from the Jerome Golden Center show that after Horowitz

completed five appointments with Dr. Sultana, she had three other medication

management appointments with other providers. Horowitz went several months

between these appointments.

        Other evidence before the ALJ about Horowitz’s mental health status came

from a mini-mental status exam that Dr. Daryace performed when he examined

her. He reported that Horowitz was alert and oriented; that she had intact cognitive

functions, good judgment and insight, and a logical thought process; that she could

recall five of five objects after 20 minutes; and that she could perform two-step

instructions without difficulties. In addition, two other state agency psychologists

who reviewed Horowitz’s records (but neither treated nor examined her) opined

that based on their review Horowitz could understand, remember, and carry out

simple tasks; relate adequately to co-workers and supervisors; and adapt to simple

changes and avoid hazards in a routine work environment.

B.      The ALJ’s Decision

        After the hearing, the ALJ denied Horowitz’s application for benefits. The

ALJ concluded that Horowitz was not engaged in substantial gainful activity and

had severe impairments including lumbar and cervical spine disorder, chronic pain

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syndrome, fibromyalgia, myofascitis, post-traumatic stress disorder, and mood

disorder. But the ALJ found that Horowitz’s impairments did not meet or

medically equal the severity of a listed impairment.

      The ALJ then found that Horowitz had the residual functional capacity to

stand or walk for six hours a day, sit for six hours a day, lift or carry and push or

pull up to 20 pounds occasionally and up to ten pounds frequently. The ALJ

further concluded that Horowitz could understand, remember, and carry out simple

tasks and job instructions; sustain concentration and persistence for two-hour

periods; and have brief, superficial interactions with supervisors, coworkers, and

the general public.

      The ALJ found that Horowitz’s testimony about her symptoms was not

credible. Although Horowitz’s symptoms could reasonably be expected to produce

her pain or other symptoms, the ALJ found that her testimony about the intensity,

persistence, and limiting effects of her symptoms was not entirely credible. With

respect to her physical impairments, the ALJ found that the record did not support

that Horowitz’s physical injuries were as disabling as she claimed. The ALJ noted

that the examinations of Horowitz did not reveal ineffective ambulation, abnormal

gait, significant decreases in her range of motion, or reflex abnormalities. The ALJ

also emphasized that Horowitz’s examinations included no recommendations of

invasive treatment.

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       Similarly, the ALJ found that Horowitz’s mental limitations were not as

disabling as she alleged. The ALJ pointed out that Dr. Sultana’s treatment notes

showed that after a few appointments, Horowitz’s affect and mood had improved.

The ALJ noted that despite claiming disabling mental symptoms, Horowitz’s

mental status exams were conservative in nature, reflecting that although there

were some deficits, she had a goal-oriented thought process, appropriate

orientation, and fair memory. The ALJ also noted that a consulting exam, which

included a mini-mental status exam, showed that Horowitz had good judgment and

insight, a functioning memory, and the ability to follow two-step directions. 1 The

ALJ also relied on the fact that Horowitz’s appointments had not become more

frequent over time due to increasing symptoms, changes in medication, changes in

clinical signs, or test results.2 Given the limited treatment that Horowitz received

for both her physical and mental impairments, the ALJ noted that she had not

generally received the type of medical treatment that one would expect for a totally

disabled individual.

       The ALJ also addressed the weight it should assign to the providers’

opinions assessing Horowitz’s residual functional capacity. The ALJ generally

gave controlling weight to the assessments of Horowitz’s treating doctors but gave

       1
          Although the ALJ stated that Dr. Kammer performed this examination, the record
clearly reflects that Dr. Daryace performed it.
       2
         The ALJ also found that Horowitz’s credibility was further reduced because she
received unemployment benefits during the relevant period of disability.
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little weight to Dr. Sultana’s opinions. The ALJ explained that Dr. Sultana’s

opinions were not consistent with the record as a whole or the objective medical

evidence in the file revealing Horowitz’s conservative mental status exam findings.

      Given Horowitz’s residual functional capacity, the ALJ found that Horowitz

was unable to continue her past relevant work as a sales clerk. But the ALJ found

that given Horowitz’s residual functional capacity she could work as a laundry

worker or mail clerk. Because there were a significant number of jobs in the

national economy that she could perform, the ALJ found that Horowitz was not

disabled.

C.    The Appeals Council’s Review

      Horowitz sought review of the ALJ’s decision from the Appeals Council.

She submitted additional evidence to the Appeals Council, including two

questionnaires completed by Dr. Busch, her treating rheumatologist. Dr. Busch

completed the questionnaires approximately three months after the ALJ rendered

her decision but gave no indication whether his opinion was based on his two

previous appointments, which occurred more than nine months earlier, or a

subsequent appointment that occurred after the ALJ rendered her decision.

      In these questionnaires, Dr. Busch opined that Horowitz was unable to work.

In the first questionnaire, Dr. Busch stated that Horowitz could lift or carry no

more than 5 pounds, could stand or walk for zero hours a day, and could sit for

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zero hours a day. He further explained that she could never climb, balance, stop,

crouch, kneel, or crawl. Although the questionnaire asked Dr. Busch to identify

the medical findings that support his opinions, he provided no such medical

findings.

      In the second questionnaire, which focused on fibromyalgia, Dr. Busch

opined that Horowitz could not work. He explained that she had issues with

chronic pain and that she was on chronic pain medications. He indicated that

Horowitz’s pain has lasted for three or more months and the pain was located in 11

or more pressure points. He explained that she also had stiffness, irritable bowel

syndrome, tension headaches, paresthesias, sleep disturbance, chronic fatigue,

memory loss, and inability to ambulate effectively.

      The Appeals Council denied Horowitz’s request to review the ALJ’s

decision. The Appeals Council explained that it had not considered Dr. Busch’s

questionnaires because they concerned a later time period.

D.    District Court Proceedings

      Horowitz then filed an action in federal district court, asking the court to

reverse the Commissioner’s decision. After briefing, the magistrate judge prepared

a report and recommendation that the district court affirm the Commissioner’s

decision. Horowitz objected. The district court overruled Horowitz’s objections,

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adopted the magistrate judge’s recommendation, and affirmed the Commissioner’s

decision. Horowitz has appealed that decision.

                          II.      STANDARD OF REVIEW

      We review the Commissioner’s decision to determine if it is supported by

substantial evidence, but we review de novo the legal principles upon which the

decision is based. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005).

“Even if we find that the evidence preponderates against the [] decision, we must

affirm if the decision is supported by substantial evidence.” Barnes v. Sullivan,

932 F.2d 1356, 1358 (11th Cir. 1991). Substantial evidence refers to “such

relevant evidence as a reasonable person would accept as adequate to support a

conclusion.” Moore, 405 F.3d at 1211. Our limited review precludes us from

“deciding the facts anew, making credibility determinations, or re-weighing the

evidence.” Id.

      Furthermore, we review the Appeals Council’s decision not to consider

additional evidence that Horowitz submitted de novo. Washington v. Soc. Sec.

Admin., Comm’r, 806 F.3d 1317, 1321 (11th Cir. 2015).

                                III.   LEGAL ANALYSIS

      An individual claiming disability benefits must prove that she is disabled.

42 U.S.C. § 423(a)(1)(E). To determine whether a claimant is “disabled,” the ALJ

applies a sequential process and examines whether the claimant: (1) is engaging in

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substantial gainful activity; (2) has a severe and medically determinable

impairment; (3) has an impairment or combination of impairments that satisfies the

criteria of a “listing”; (4) can perform her past relevant work in light of her residual

functional capacity; and (5) can adjust to other work in light of her residual

functional capacity, age, education, and work experience. 20 C.F.R.

§ 404.1520(a)(4).

      On appeal, Horowitz asserts that the ALJ erred in analyzing her residual

functional capacity because the ALJ failed to give proper weight to the opinion of

her treating psychologist, Dr. Sultana, and improperly discounted her testimony

regarding her pain and other symptoms. She also argues that the Appeals Council

erred when it refused to consider the additional materials from Dr. Busch. We

consider these arguments in turn.

A.    The ALJ Did Not Err in Giving Little Weight to Dr. Sultana’s Opinion.

      Horowitz first contends that the ALJ erred in determining her residual

functional capacity by giving little weight to the opinion of her treating

psychiatrist, Dr. Sultana. We disagree.

      The ALJ must give a treating physician’s opinion “substantial or

considerable weight unless good cause is shown to the contrary.” Phillips v.

Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2004) (internal quotation marks

omitted); see 20 C.F.R. § 404.1527(c)(2). Good cause exists when: (1) the opinion

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“was not bolstered by the evidence,” (2) the “evidence supported a contrary

finding,” or (3) the “treating physician’s opinion was conclusory or inconsistent

with the doctor’s own medical records.” Phillips, 357 F.3d at 1240-41. We have

explained that “[t]he ALJ must clearly articulate the reasons for giving less weight

to the opinion of a treating physician, and the failure to do so is reversible error.”

Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). But if an ALJ articulates

specific reasons for declining to give the opinion of a treating physician controlling

weight, and those reasons are supported by substantial evidence, there is no

reversible error. Moore, 405 F.3d at 1212.

      Horowitz contends that the ALJ erred in failing to give Dr. Sultana’s

opinions substantial or considerable weight. But the ALJ explained that Dr.

Sultana’s opinions were not entitled to controlling weight because they were

inconsistent with the record as a whole or the objective medical evidence in the

record. Substantial evidence supports the conclusion. Although Dr. Sultana

opined that Horowitz’s mental impairments left her unable to work, the record

reflects that Dr. Sultana provided conservative mental health treatment, which

consisted only of 15-minute medication management appointments. The

conservative and routine nature of this treatment plan suggests that Horowitz’s

impairments—while significant—were not so severe that she could not perform

any job duties. See Wolfe v. Chater, 86 F.3d 1072, 1078 (11th Cir. 1996)

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(recognizing that a physician’s conservative medical treatment for a particular

condition may negate a claim of disability). 3

       Dr. Sultana’s opinion that Horowitz’s concentration was impaired was

contradicted by the medical evidence in the record. First, it was contradicted by

Dr. Sultanta’s own records, which indicated that Horowitz’s concentration was fair

with no noted impairments. In addition, the opinion was contradicted by Dr.

Daryace’s mini-mental status exam, which showed that Horowitz’s memory was

intact. Viewing this evidence together, we conclude that the ALJ’s conclusion

that Dr. Sultana’s opinions were contradicted by other evidence is supported by

substantial evidence.

       We also observe that the ALJ could have disregarded Dr. Sultana’s opinions

on the basis that they were wholly conclusory. Although Dr. Sultana opined that

Horowitz was unable to work and that her concertation was impaired, Dr. Sultana

gave no explanation to support these opinions, even though the form that Dr.

       3
         We pause to note that if a claimant failed to seek treatment altogether or comply with a
course of treatment prescribed by a provider, an ALJ may not rely on the lack of treatment or
noncompliance to conclude that claimant was not disabled. An ALJ is prohibited from drawing
“any inferences about an individual’s symptoms and their functional effects from a failure to
seek or pursue regular medical treatment without first considering any explanations that the
individual may provide.” Social Security Regulation 96-7p (SSR 96-7) at 7; see Henry v.
Comm’r of Soc. Sec., 802 F.3d 1264, 1268 (11th Cir. 2015). As such, an ALJ must consider
evidence showing that the claimant is unable to afford medical care before denying benefits
based upon the claimant’s non-compliance with prescribed care. See Ellison v. Barnhart, 355
F.3d 1272, 1275 (11th Cir. 2003). But the ALJ could consider that while treating Horowitz, Dr.
Sultana did not recommend a more frequent or intense treatment plan than monthly medication
management appointments.
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Sultana used asked her to provide behavioral objective data that supported them.

After careful consideration, we simply cannot say that the ALJ erred in assigning

little weight to Dr. Sultana’s opinions. 4

B.     The ALJ Did Not Err in Determining that Horowitz Was Not Credible.

       We must next consider whether the ALJ erred in finding that Horwitz’s

subjective complaints about the intensity, persistence, and limiting effects of her

symptoms were not credible. Horowitz testified before the ALJ about her physical

and emotional impairments. She described the pain that she experienced as a result

of her fibromyalgia and how her depression left her unable to leave her house most

days. She also explained that she walked with a cane because of injuries she

suffered to her right leg when she was abducted. Although Horowitz asserts that

the ALJ erred by rejecting her subjective description of her symptoms, given our

deferential standard of review, we discern no error.

       When a claimant attempts to establish a disability through her own

testimony concerning pain or other subjective symptoms, we require “(1) evidence

of an underlying medical condition; and (2) either (a) objective medical evidence

confirming the severity of the alleged pain; or (b) that the objectively determined

       4
          Horowitz also argues that the case should be remanded to the ALJ because it is
impossible to determine from the ALJ’s opinion whether she assigned significant weight or little
weight to Dr. Sultana’s opinions. Certainly, remand is required if we are “unable to determine
whether the ALJ . . . gave the treating [source’s] evidence substantial or considerable weight or
found no good cause to do so.” Wiggins v. Schweiker, 679 F.2d 1387, 1390 (11th Cir. 1982).
But because we can discern that the ALJ gave Dr. Sultana’s opinion little weight, no remand is
required.
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medical condition can reasonably be expected to give rise to the claimed pain.”

Wilson v. Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002). If the record shows that

the claimant has a medically determinable impairment that could reasonably be

expected to produce her symptoms, the ALJ must evaluate the intensity and

persistence of the symptoms to determine how they limit the claimant’s capacity

for work. 20 C.F.R. § 404.1529(c)(1). In assessing the claimant’s credibility about

her symptoms and their effects, the ALJ will consider in addition to the objective

medical evidence: the individual’s daily activities; the location, duration,

frequency, and intensity of the individual’s symptoms; precipitating and

aggravating factors; the type, dosage, effectiveness, and side effects of medication

taken to relieve the symptoms; treatment, other than medication, for the symptoms;

any other measure used to relieve the symptoms; and any other factors concerning

functional limitations and restrictions due to the symptoms. Id. § 404.1529(c)(3).

      We have recognized that unique issues arise when a claimant suffers from

fibromyalgia. Fibromyalgia “often lacks medical or laboratory signs, and is

generally diagnosed mostly on a[n] individual’s described symptoms.” Moore,
405 F.3d at 1211. Because the “hallmark” of fibromyalgia is a “lack of objective

evidence,” a claimant’s subjective complaints may be the only means of

determining the severity of the claimant’s condition and the functional limitations

she experiences. Id. This Court will reverse an ALJ’s determination that a

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fibromyalgia claimant’s testimony was incredible where the lack of objective

findings provided the basis for the adverse credibility determination. Id.

      Here, the ALJ found that because Horowitz’s subjective complaints were

inconsistent with the medical evidence in this case, her testimony was not credible.

The ALJ pointed out that Horowitz’s physical examinations showed no ineffective

ambulation, abnormal gait, significant decrease in range of motion, sensory

changes, reflex abnormalities, or deficiencies in positive straight leg raises.

Horowitz argues that because her conditions were caused by fibromyalgia, the ALJ

could not rely on the lack of objective evidence to make an adverse credibility

determination. The flaw in Horowitz’s argument is that she testified that at least

some of her physical impairments, such as the injuries to her right leg that required

her to walk with a cane, were the result of injuries she suffered when she was the

victim of a violent crime. As such, it was appropriate for the ALJ to consider

whether there was objective evidence corroborating this injury. And because there

are no objective findings—such as evidence that she had ineffective ambulation or

abnormal gait—to corroborate her account about the symptoms and pain in her

right leg, substantial evidence supported the ALJ’s credibility determination.

      The ALJ’s credibility determination is supported by substantial evidence for

a second reason as well: Horowitz received conservative treatment for her

impairments. ALJs are permitted to consider the type of a treatment a claimant

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received in assessing the credibility of her subjective complaints. 20 C.F.R.

§ 405.1529(c)(3)(iv), (v); see Wolfe, 86 F.3d at 1078. As we explained above, for

Horowitz’s mental impairments, her treatment plan was conservative in nature and

essentially limited to short medication management appointments. Similarly, for

her physical impairments, Dr. Busch provided conservative treatment for

Horowitz’s pain and never indicated that she should have been receiving more or

different treatments. In light of this evidence, we conclude that the ALJ’s adverse

credibility determination was appropriate.

C.    The Appeals Council Did Not Err in Refusing to Consider Horowitz’s
      Additional Evidence.

      Horowitz argues that the Appeals Council erred in refusing to consider the

additional evidence that she submitted from Dr. Busch. “[T]he Appeals Council

must consider new, material, and chronologically relevant evidence that the

claimant submits. Washington, 806 F.3d at 1320 (internal quotation marks

omitted). We have explained that evidence is chronologically relevant when it

relates to the period or on before the date of the ALJ’s decision. Id. at 1322. An

examination conducted after the ALJ’s decision may still be chronologically

relevant if it relates back to the period before the ALJ’s decision. Id.

      Here, the Appeals Council appropriately determined that Dr. Busch’s

opinions were not chronologically relevant. Dr. Busch issued his opinions after the

ALJ rendered her decision. Nonetheless, Horowitz argues that Dr. Busch’s
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opinions are chronologically relevant because they were based on care that Dr.

Busch provided before the ALJ rendered her decision. The problem for Horowitz

is that there is nothing in Dr. Busch’s opinions showing that he based them on

treatment provided to Horowitz before the ALJ’s decision.

      Horowitz asserts that our opinion in Washington shows that Dr. Busch’s

opinions are chronologically relevant. But in Washington, we held that the opinion

of a psychologist who examined the claimant after the ALJ’s decision was

chronologically relevant when the psychologist stated in his opinion that his

conclusions were based on, among other things, his review of the medical records

from the period before the ALJ’s decision. See 806 F.3d at 1322. Dr. Busch’s

opinions fail to show directly or indirectly that he based his opinion on medical

records from the time period before the ALJ’s decision, making Washington

inapplicable here. Dr. Busch’s opinions were not chronologically relevant; we thus

hold that the Appeals Council properly refused to consider them.

                                IV.   CONCLUSION

      For the reasons set forth above, we affirm the Commissioner’s decision to

deny Horowitz benefits.

      AFFIRMED.

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