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Edwards v. Saul

United States District Court, D. New Hampshire

December 31, 2019

Jennifer Edwards
Andrew Saul,[1] Commissioner, Social Security Administration

          Edward A. Wicklund, Esq. Janine Gawryl, Esq. Hugh Dun Rappaport, Esq.



         Jennifer Edwards challenges the denial of her claims for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), respectively. She contends that the Administrative Law Judge (“ALJ”) erred by (1) failing to give proper weight to the opinion of an examining physician; (2) failing to give proper weight to the opinion of Edwards's treating physician; and (3) failing to properly consider whether Edwards's impairments met or equaled Listing 1.02 or 1.04. 20 C.F.R. Pt. 404, Subpt. P, App. 1. The Commissioner, in turn, moves for an order affirming the ALJ's decision. For the following reasons, I deny Edwards's motion and affirm the decision of the Commissioner.

         I. BACKGROUND

         The parties have submitted statements of material facts as required by Local Rule 9.1(b). Many of the relevant facts are set out in a previous decision by this court, Edwards v. Berryhill, No. 17-cv-232-AJ, 2018 WL 1221159 (D.N.H. Mar. 7, 2018). I decline to repeat them here in detail. Rather, I focus on facts relevant to this appeal, including facts developed after the previous decision was issued.

         A. Procedural Facts

         Edwards filed her current claim for DIB and SSI in February 2012, alleging a disability onset date of May 6, 2009. Tr. at 150. After an initial denial in May 2012, Edwards's claim was heard before ALJ Ruth Kleinfeld in July 2013. Tr. at 173. The ALJ issued an unfavorable decision that November, Tr. at 173-82, which Edwards appealed to the Appeals Council. Tr. at 187. The Appeals Council remanded Edwards's case and another hearing was conducted on November 10, 2015 before ALJ Dory Sutker. Tr. at 1209-77. ALJ Sutker addressed the issues raised by the Appeals Council but ultimately issued another unfavorable decision on December 16, 2015, Tr. at 1111-35.

         Edwards's second request for review by the Appeals Council was denied, so she appealed to this court. Tr. at 1141-46. Edwards raised several issues with the ALJ's opinion, including that the ALJ's decision to discount the opinion of examining physician Dr. Frank Graf was not supported by substantial evidence. The ALJ had discounted Dr. Graf's opinion because she found that the responses on Dr. Graf's medical source statement were contradictory, that Dr. Graf's opinions were not supported by the report he prepared, and that Dr. Graf's opinion on Edwards's capacity for sitting was not consistent with Edwards's own testimony. Edwards, 2018 WL 1221159, at *7.

         On March 7, 2018, Magistrate Judge Johnstone remanded Edwards's case to the Commissioner on the grounds that none of these reasons was sufficient for discounting Dr. Graf's opinion. Id. First, she found that the apparently contradictory responses in Dr. Graf's statement were most logically explained as an inadvertent transposing of two answers. Id. at *6. Next, she determined that the ALJ's assertion that Dr. Graf's opinions were not supported by evidence was conclusory and that Dr. Graf had, in fact, provided examination findings to back up his conclusions. Id. Finally, she concluded that, while the ALJ had found that Dr. Graf's opinion that Edwards should be limited to one hour of sitting was inconsistent with Edwards's testimony about how she spent her days, Magistrate Judge Johnstone determined that there was no inconsistency because Edwards had stated that she spent most of her time reclining, and reclining is distinct from sitting. Id. at *7.

         Magistrate Judge Johnstone also identified several issues for the Commissioner to address on remand. Id. Specifically, Magistrate Judge Johnstone noted instances where the ALJ misstated Edwards's history of hospitalization, misidentified a non-medical SSA employee as a “medical physician, ” improperly afforded weight to the fact that Dr. Graf was the only physician who noted an issue with Edwards's right ankle reflexes, and provided insufficient justification for giving “greatest weight” to the opinion of expert medical witness Dr. John Kwock. Id. at *8-9.

         On remand, ALJ Sutker conducted a third hearing on November 20, 2018, Tr. at 894-975, and issued an unfavorable decision on February 26, 2019, Tr. at 870-87. The Appeals Council denied review, and Edwards appealed to this court.

         B. Medical Evidence

         Edwards's disability claim is principally based upon failed back surgeries (in July 2009 and January 2014) and a failed knee replacement (in August 2013). Tr. at 900-01. Edwards has also been diagnosed with mental impairments, such as bipolar disorder, depression, and anxiety. Tr. at 619, 625, 627. In addition to surgical intervention, Edwards has been treated with numerous prescription medications. See Pl.'s Statement of Material Facts, Doc. No. 8-1 at 1 (listing medications). She also claims to suffer some side effects of these medications related to her memory and motor function. Tr. at 377.

         Since at least 2009, Dr. Melissa Hanrahan has treated Edwards for these and other ailments. Tr. at 409. In addition to years of treatment records, Dr. Hanrahan provided two medical opinions relevant to this appeal. First, in June 2013, she completed a form that rated Edwards's limitations in various categories from “Mild or None” to “Extreme.” Tr. at 688-89. On this form, Dr. Hanrahan further concluded that Edwards could not sustain an average eight-hour workday because her “severe anxiety [and] panic limits her ability to focus at work.” Tr. at 689. Second, in October 2015, Dr. Hanrahan provided a letter that stated that Edwards “could not work a full day due to fatigue, chronic pain and needing to change positions frequently.” Tr. at 864.

         Dr. Graf performed a consultative examination of Edwards in April 2015. Tr. at 792-801. He identified substantial impairments in Edwards's ability to bend, stoop, lift, and carry, with diminished tolerance for walking. Tr. at 793. Specifically, Dr. Graf opined that Edwards could never lift more than twenty pounds or carry more than ten pounds. Tr. at 795. Additionally, he found that she could only spend one hour sitting, thirty minutes standing, and twenty minutes walking in an eight-hour workday, with the remainder of her time to be spent reclining. Tr. at 796.

         At the hearing, ALJ Sutker heard testimony from Dr. Darius Ghazi, an orthopedic surgeon who had reviewed Edwards's medical records. Tr. at 920-21. After recounting some of Edwards's treatment history, Dr. Ghazi opined that Edwards met the criteria for Listing 1.02A and 1.04C. Tr. at 923. When asked which objective medical evidence in the record supported a finding that Edwards could not ambulate effectively, as is required by 1.02A, Dr. Ghazi stated only that he believed that anyone with a knee replacement has an inability to ambulate effectively. Tr. at 925. When asked which objective medical evidence in the record documented pseudo-claudication, as required by Listing 1.04C, Dr. Ghazi replied that he “didn't see anything.” Tr. at 926.

         Dr. Ghazi opined that Edwards could lift five pounds frequently and ten pounds occasionally. Tr. at 927. He believed she could stand and/or walk for two hours at a time for a total of about four hours in an eight-hour workday, sit for six hours, and occasionally require a cane to walk. Tr. at 928. Dr. Ghazi disagreed with several of Dr. Graf's findings. Specifically, Dr. Ghazi believed that Dr. Graf had overstated Edwards's capacity for carrying, Tr. at 933, and thought that there was no objective medical evidence to support Dr. Graf's restrictions on Edwards's use of her arms and her capacity for sitting, Tr. at 936-37.

         Edwards had two consultative examinations for her mental impairments: one in May 2012 by Dr. Michael Evans, Tr. at 584- 87, and one in May 2015 by Dr. Trina Jackson, Tr. at 782-91. While these two doctors noted that Edwards had had psychological issues in the past, they both found her to have mild to no mental impairments at present. Tr. at 586-87 (listing normal or mildly limited levels of functioning in all categories and a “good” psychiatric prognosis), 785 (noting “good” social skills, “intact” memory and cognition, “good” concentration and persistence, and “mild difficulty with stress tolerance”).

         C. The ALJ's Decision

         At step one of the five-step disability evaluation process, ALJ Sutker found that Edwards had not engaged in substantial gainful activity since May 6, 2009, her alleged disability onset date. Tr. at 875. At step two, she found that Edwards had several severe impairments: “chondromalacia and osteoarthritis of the left knee, status post total knee replacement; degenerative disc disease of the lumbar spine; obesity; bipolar disorder; anxiety[;] and depression.” Tr. at 875.

         Relevant to this appeal, at step three, the ALJ considered whether Edwards's impairments met or equaled Listing 1.02 or 1.04.[2] Tr. at 876. The ALJ recounted the criteria of Listing 1.02 and found that there was “no evidence” to support a finding that Edwards met them. Tr. at 876. The ALJ then recounted the criteria of Listing 1.04 and found that the evidence did not demonstrate that it was “met or medically equaled in this case.” Tr. at 876.

         After finding that Edwards did not meet or equal any listed impairment, the ALJ formulated her Residual Functional Capacity (“RFC”). Tr. at 878. Specifically, the ALJ determined that Edwards had the RFC to perform sedentary work, subject to several additional restrictions. Relevant to this appeal, she determined that Edwards could “lift and carry ten pounds occasionally and five pounds frequently; sit for a total of six hours and stand and/or walk for four hours total out of an eight-hour workday with normal breaks” Tr. at 878. The ALJ also found that Edwards would need to use a cane at her discretion when ambulating and that, although her “pace is somewhat variable, . . . she is able to stay on task at least 90% of the workday.” Tr. at 878.

         In reaching this conclusion, the ALJ determined that Dr. Hanrahan's checklist-style form had “little to no probative value because it is not supported by any objective evidence.” Tr. at 884. Specifically, the ALJ found that Edwards's daily activities, such as “babysitting, preparing simple meals[, ] and performing light household chores” were inconsistent with the Edwards's “allegations of disabling functional limitations.” Tr. at 884. With regard to Dr. Hanrahan's 2015 opinion that Edwards “could not work a full day due to fatigue [and] chronic pain and needed to change positions frequently, ” the ALJ noted that she was “not persuaded” because the opinion was “conclusory in nature, fails to give disabling limitations[, ] and is an assessment of [Edwards's] ability to engage in basic work[-]like activities, which is an opinion reserved to the Commissioner.” Tr. at 885. Although the ALJ did not assign Dr. Hanrahan's opinion “the controlling weight ordinarily assigned to a treating physician[']s report commenting on the claimant's abilities, ” she did not ignore Dr. Hanrahan's observations and findings and “carefully considered [them] in providing insight as to functional ability and how they affect [Edwards's] ability to work.” Tr. at 885.

         The ALJ gave “some weight” to Dr. Graf's 2015 opinion. Tr. at 884. After summarizing Dr. Graf's findings, the ALJ gave Dr. Graf's opinion less weight than would ordinarily be assigned to an examining physician because “more contemporaneous treatment notes do not support [Dr. Graf's] restrictions in standing and walking. Specifically, physical examinations recently showed no gait abnormalities and described [Edwards] as active in performing daily activities and household chores.” Tr. at 884. The ALJ also noted that Dr. Ghazi had disagreed with some aspects of Dr. Graf's report. Tr. at 883. Specifically, Dr. Ghazi could find no evidence to support Dr. Graf's restrictions on Edwards's standing and walking other than her history of reconstructive surgery, and he was unable to find any support in the record at all for Dr. Graf's opined limitations on Edwards's sitting and use of her upper extremities. Tr. at 883.

         Overall, the ALJ gave “great weight” to the opinion of Dr. Ghazi, based upon an evaluation several factors, including “supportability, including the degree of explanation and support by objective evidence; consistency with the record as a whole; [and] degree of specialization in the area of medicine involved.” Tr. at 883. The ALJ noted that “Dr. Ghazi is an orthopedic surgeon, he has an awareness of all the evidence in the record, and he has an understanding of social security disability programs and evidentiary requirements.” Tr. at 883. “Most importantly, his opinion regarding [Edwards's] functional limitations is highly persuasive because it is well-supported by the objective medical evidence.” Tr. at 883-84.

         The ALJ gave “some weight” to the 2012 opinion of Dr. Evans because “more recent treatment notes showed relatively normal mental status examination and good control of depression and anxiety with prescribed medication.” Tr. at 881. She also gave “great weight” to the opinion of Dr. Jackson because she was an examining physician who “had an opportunity to observe [Edwards].” Tr. at 881-82. However, while Dr. Jackson had opined no limitations in Edwards's ability to stay on task during the workday, the ...

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