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Garza v. Berryhill

United States District Court, S.D. Indiana, Terre Haute Division

September 29, 2017

TAMMY L. GARZA, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, [1] Defendant.


          Hon. William T. Lawrence, Judge.

         Plaintiff Tammy L. Garza requests judicial review of the final decision of the Defendant, Nancy A. Berryhill, Acting Commissioner of the Social Security Administration (“Commissioner”), denying Garza's applications for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”). The Court, having reviewed the record and the briefs of the parties, rules as follows.


         Disability is defined as “the inability to engage in any substantial gainful activity by reason of a medically determinable mental or physical impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of at least twelve months.” 42 U.S.C. § 423(d)(1)(A). In order to be found disabled, a claimant must demonstrate that her physical or mental limitations prevent her from doing not only her previous work, but any other kind of gainful employment which exists in the national economy, considering her age, education, and work experience. 42 U.S.C. § 423(d)(2)(A).

         In determining whether a claimant is disabled, the Commissioner employs a five-step sequential analysis.[2] At step one, if the claimant is engaged in substantial gainful activity, she is not disabled, despite her medical condition and other factors. 20 C.F.R. § 404.1520(b). At step two, if the claimant does not have a “severe” impairment (i.e., one that significantly limits her ability to perform basic work activities), she is not disabled. 20 C.F.R. § 404.1520(c). At step three, the Commissioner determines whether the claimant's impairment or combination of impairments meets or medically equals any impairment that appears in the Listing of Impairments, 20 C.F.R. pt. 404, subpt. P, App. 1, and whether the impairment meets the twelvemonth duration requirement; if so, the claimant is deemed disabled. 20 C.F.R. § 404.1520(d). At step four, if the claimant is able to perform her past relevant work, she is not disabled. 20 C.F.R. § 404.1520(f). At step five, if the claimant can perform any other work in the national economy, she is not disabled. 20 C.F.R. § 404.1520(g).

         In reviewing the Administrative Law Judge's (“ALJ”) decision, the ALJ's findings of fact are conclusive and must be upheld by this court “so long as substantial evidence supports them and no error of law occurred.” Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). “Substantial evidence means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, ” id., and this Court may not reweigh the evidence or substitute its judgment for that of the ALJ. Overman v. Astrue, 546 F.3d 456, 462 (7th Cir. 2008). In order to be affirmed, the ALJ must articulate his analysis of the evidence in his decision; while he “is not required to address every piece of evidence or testimony presented, ” he must “provide an accurate and logical bridge between the evidence and [his] conclusion that a claimant is not disabled.” Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012). “If a decision lacks evidentiary support or is so poorly articulated as to prevent meaningful review, a remand is required.” Id. (citation omitted).


         Garza applied for Disability Insurance Benefits and Supplemental Security Income benefits in November 2006, alleging disability since March 13, 1997. The Agency denied Garza's claims initially on February 15, 2007. On March 27, 2008, following a hearing requested by Garza, ALJ Dale Garwal found that Garza became disabled as of November 3, 2006, but was not disabled prior to that date. As Garza's insured status had expired on December 31, 1997, the ALJ's finding precluded an award of Disability Insurance Benefits, and Garza requested review, which the Appeals Council denied on April 14, 2010. Garza appealed to the United States District Court for the Central District of California, which remanded the case on June 13, 2011, concluding that the ALJ erred in evaluating the medical evidence and erred in applying res judicata since there was no evidence of a prior decision. Following a second hearing and a third supplemental hearing, ALJ William Sampson issued a decision on April 18, 2013, which Garza appealed to the Appeals Council. This time the Council remanded the case, noting that ALJ Sampson had not evaluated the treating physician opinion of Dr. Taban. After a fourth hearing, ALJ Sampson again denied benefits for the period prior to October 2010. As the Appeals Council did not assume jurisdiction, the ALJ's decision became the final decision of the Commissioner. See 20 C.F.R. § 404.984. Garza filed this timely appeal.


         At step one of the sequential evaluation, the ALJ determined that Garza had not engaged in substantial gainful activity since the alleged onset date. At steps two and three, the ALJ concluded the claimant suffered from the following severe impairments: effects of multi-level lumbar fusions, with degenerative changes and obesity, with an additional severe impairment after October 1, 2010, of listing level rheumatoid arthritis.

         At step four, the ALJ determined that, prior to October 1, 2010, Garza could perform sedentary work with: occasional climbing of ramps and stairs; no climbing of ladders, ropes, or scaffolding; occasionally balancing, stooping, kneeling, crouching, or crawling; frequent handling; avoiding concentrated exposure to extreme temperatures, wetness, humidity, and vibrations; no work at unexposed heights or dangerous moving machinery; occasionally operating foot controls; and the option to alternate between sitting and standing at least once every thirty minutes for at least five minutes at a time. Id. The ALJ concluded that prior to October 1, 2010, Garza could not perform her past work but could perform a significant number of other jobs. Accordingly, the ALJ concluded that, prior to October 1, 2010, Garza was not disabled as defined by the Act.


         The medical evidence of record is aptly set forth in Garza's brief (Dkt. No. 20) and need not be recited here. Specific facts are set forth in the discussion section below where relevant.

         V. DISCUSSION

         In her brief in support of her complaint, Garza advances several objections to the ALJ's decision; each is addressed below.

         A. Weight Given to Treating Physicians

         Garza argues that the ALJ failed to properly assess the treating physician opinions of Drs. Nagalberg and Taban. These arguments are addressed, in turn, below.

         Under the law as it existed at the time of the ALJ's decision, [3] a treating source's opinion is entitled to controlling weight if the “opinion on the issue(s) of the nature and severity of [the claimant's] impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence” in the record. 20 C.F.R. § 404.1527(c)(2); see Bates v. Colvin, 736 F.3d 1093, 1099 (7th Cir. 2013). The ALJ must “minimally articulate his reasons for crediting or rejecting evidence of disability.” Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1076 (7th Cir. 1992)); see 20 C.F.R. § 404.1527(c)(2) .

         An ALJ must give a treating physician's opinion controlling weight if it is both “(1) supported by medical findings; and (2) consistent with substantial evidence in the record.” Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008) (citing 20 C.F.R. § 404.1527(c)(2)). If the ALJ finds that the opinion is not entitled to controlling weight, the ALJ must still assess the proper weight to give to the opinion. See Id. This requires consideration of several factors, including the “length, nature, and extent of the physician and claimant's treatment relationship, whether the physician supported his or her opinions with sufficient explanations, and whether the physician specializes in the medical conditions at issue.” Id. (citations omitted).

         Garza first argues that the ALJ failed to give adequate weight to the opinion of treating physician Dr. Steven Nagelberg and failed to comply with all provisions of 20 C.F.R. § 404.1527 in evaluating the treating physician's opinion.

         With respect to Dr. Nagelberg's opinion, the ALJ found the following:

For example, after this most recent surgery the claimant was seen by Dr. Nagelberg in January 2004 leaving a gap in care; there was no evidence of emergency room care or symptom exacerbation, but on the follow up the claimant's lumbar flexion was now limited to 40º, her extension to 10º, and she complained of ongoing pain (Exhibit 12F). Conversely, the claimant's motor function remained intact, she continued to be able to heel/toe walk despite decreased reflexes in her lower extremities, and her straight leg raise test (SLR) was now negative (Id.). At the March exam, the claimant's flexion had increased by 20º to 60º, her extension remained the same at 10º (Id.). The claimant continued to have reduced lower extension reflexes but her sensations remained intact (Id.). At her April 2004 revaluation, the claimant endorsed severe pain but surprisingly she had near full flexion (Id.). The physician was able to appreciate tenderness over the paraspinal muscles, but he found no neurologic deficits in the lower extremities (Id.). Again, without much clinical evidence, and based apparently on the claimant's subjective reports, the physician opined throughout the foregoing period that the claimant was “temporarily totally disabled” (Exhibit 5F, 12F). Doctors Nagelberg and Gitter saw the claimant during this period establishing a treating relationship with claimant, but there was little clinical evidence to support the foregoing opinions. To the contrary, the claimant's range of movement increased, she was not neurologically deficient, and her straight leg raise test (SLR) was afforded little deference. This was well supported as the limitations noted by the examining physicians did not match the actual claimant's functionality (Id.). In fact, the only abnormality noted, the claimant's subjective allegations of severe pain as her range of movement was generally within normal limits (Id.). Furthermore, as noted throughout this decision, these workers' compensation physician opinions touched on issues clearly reserved for the Commissioner, and appeared to have been based on State law, not the laws and regulations that govern this Agency.
In June of that same year, during another follow up with Nagelberg, the claimant reported low back pain with radiation into the legs; the accompanying exam notes remained consistent through February 2005 (Id.). During these exams, the claimant continued to subjectively report ongoing severe pain, claiming that at times she was essentially bedridden due to pain (Id.). While she was found tender in the paraspinal region bilaterally on exam with decreased spinal ranges of movement, she remained neurologically intact (Id.). There were no objective references to sensory deficits, the claimant's reflexes were now intact and symmetrical, and her straight leg raise test (SLR) remained negative at 90º suggesting that despite the foregoing fusion, she had no residual range of movement limitations (Id.). The claimant was also able to stand and heel/toe walk without difficulty (Id.). The only continuing course of treatment at this was medication based (Exhibit 12F).
The claimant did undergo an injection in December after reporting radicular symptomology, and her workers' compensation physician again opined that she remained 100% disabled under the “California Worker's Compensation Laws” (Id.). Yet, as noted above, it is clear that the physician was not basing these opinions in Social Security Law, and as explained throughout this decision and incorporated by reference herein, little weight was afforded to this statement as the determination of disability is for the Commissioner. Interestingly, at the time of this assessment, the same physician noted that the claimant was at maximum medical improvement, but that she needed a referral for a detoxification program due to her prolonged use of narcotic pain medications (Id.). Other issues included the claimant's noncompliance with her ordered weight loss program and a subsequent “no show” in March 2005 (Id.). As previously stated, there is likely a financial aspect to this lack of follow up, but throughout the period of adjudication, including the period after the ...

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