ERIN L. WIEDEMANN, Magistrate Judge.
Plaintiff, William Barnard, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration ("Commissioner") denying his claim for supplemental security income ("SSI") under the provisions of Title XVI of the Social Security Act ("Act"). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision.
I. Procedural Background:
Plaintiff protectively filed his application for SSI on June 4, 2013. (ECF No. 9, pp. 19, 189). In his application, Plaintiff alleges disability due to lower back injury, protruding and herniated disks, and pain and numbness in his legs. (ECF No. 9, p. 193). Plaintiff alleges an onset date of March 21, 2012. (ECF No. 9, pp. 19, 189). This application was denied initially and again upon reconsideration. (ECF No. 9, pp. 55-76).
Thereafter, Plaintiff requested an administrative hearing on his denied application, and this hearing request was granted. (ECF No. 9, pp. 92-95). Plaintiff's administrative hearing was held on May 8, 2014, in Fort Smith, Arkansas (ECF No. 9, pp. 32-54). Plaintiff appeared in person and was represented by Nick Coleman.
After this hearing, on August 28, 2014, the ALJ entered an unfavorable decision denying Plaintiff's application for SSI. (ECF No. 9, pp. 15-26). In this decision, the ALJ found Plaintiff had not engaged in Substantial Gainful Activity ("SGA") since June 4, 2013, Plaintiff's application date. (ECF No. 9, p. 21, Finding 1). The ALJ determined Plaintiff had the following severe impairments: Musculoskeletal Disorder (Back Disorder, degenerative disc disease) (7240) and Obesity (2780). (ECF No. 9, p. 21, Finding 2). Despite being severe, the ALJ determined these impairments did not meet or medically equal the requirements of any of the Listings of Impairments in Appendix 1 to Subpart P of Part 404 ("Listings"). (ECF No. 9, pp. 21-22, Finding 3).
The ALJ then considered Plaintiff's Residual Functional Capacity ("RFC"). (ECF No. 9, pp. 22-25, Finding 4). First, the ALJ evaluated Plaintiff's subjective complaints and found his claimed limitations were not entirely credible.
Thereafter, on October 27, 2014, Plaintiff requested a review by the Appeals Council (ECF. No. 9, p. 10). The Appeals Council denied this request on November 17, 2015. (ECF No. 9, pp. 5-9). On January 20, 2016, Plaintiff filed the present appeal with this Court. (ECF No. 1). The parties consented to the jurisdiction of this Court on February 3, 2016. (ECF No. 5). This case is now ready for decision.
II. Applicable Law:
This Court's role is to determine whether substantial evidence supports the Commissioner's findings.
A claimant for Social Security disability benefits has the burden of proving his disability by establishing a physical or mental disability that has lasted at least one year and that prevents him from engaging in any substantial gainful activity.
The Commissioner's regulations require her to apply a five-step sequential evaluation process to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful activity since filing her claim; (2) whether the claimant has a severe physical and/or mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past relevant work; and, (5) whether the claimant is able to perform other work in the national economy given his age, education, and experience.
Plaintiff raises three issues on appeal: 1) the ALJ improperly discredited Plaintiff's subjective complaints; 2) the ALJ improperly relied on the Medical-Vocational Guidelines; and 3) the ALJ committed reversible error in failing to obtain additional evidence from Dr. Ted Honghiran (ECF No. 12).
A. Subjective Complaints and Credibility Analysis:
The ALJ was required to consider all the evidence relating to Plaintiff's subjective complaints including evidence presented by third parties that relates to: (1) Plaintiff's daily activities; (2) the duration, frequency, and intensity of his pain; (3) precipitating and aggravating factors; (4) dosage, effectiveness, and side effects of his medication; and (5) functional restrictions.
The record contains substantial evidence supporting the ALJ's conclusion that Plaintiff's subjective complaints were not entirely credible. Plaintiff's treatment was generally conservative and Plaintiff did not pursue the treatment options recommended to him. For example, Dr. Lee stated that he "would strongly recommend avoiding surgery," and referred Plaintiff to a pain management facility in Branson. (ECF No. 9, p. 343). The record contains no evidence Plaintiff followed up with the pain management referral. Instead, Plaintiff told Dr. Honghiran he was treating his back pain with over the counter medications because he lacked insurance and was unable to afford further treatment. (ECF No. 9, p. 353). The record contains no evidence, however, Plaintiff sought any low-cost or free healthcare services for additional treatment. On December 18, 2012, Dr. Anna Kahn, D.C., Plaintiff's chiropractor stated, "Patient reports that he is still having his [low back pain] and that this will be his last visit secondary to financial difficulties. He reports that he has pain with [range of motion], but that his pain did improve with [treatment], but that he felt that if he had more [treatment], he would have improved even more."
B. RFC Determination and Medical Opinions:
RFC is the most a person can do despite that person's limitations. 20 C.F.R. §§ 416.945. It is assessed using all relevant evidence in the record.
Plaintiff presented to Baxter Regional Medical Center on March 21, 2012, and complained of low back pain and a mild headache, and reported being involved in a motor vehicle accident approximately three and a half hours prior. (ECF No. 9, p. 275). The record indicates Plaintiff was ambulatory and in no visible distress.
Thereafter, Plaintiff followed up with Dr. Bogle on June 25, 2012. (ECF No. 9, p. 334-35). Dr. Bogle's physical examination of Plaintiff revealed some paraspinal muscular tenderness in Plaintiff's lower back, but otherwise found no abnormal results.
Plaintiff began treatment with a chiropractor on October 22, 2012. (ECF No. 9, p. 306). Plaintiff attended five treatment appointments between October 22, 2012, and December 18, 2012. (ECF No. 9, pp. 306-10). On December 18, 2012, Plaintiff's chiropractor stated, "this will be his last visit secondary to financial difficulties. He reports that he has pain with [range of motion], but that his pain did improve with [treatment], but that he felt that if he had more [treatment], he would have improved even more. . . . Will [treat] patient in future if he is able to present for care, as he did benefit from lumbar traction/decompression." (ECF No. 9, p. 310).
The record does not indicate Plaintiff ever returned for further chiropractic treatment. Instead, Plaintiff returned to Baxter Regional Medical Center four days later on December 22, 2012, and complained of continuing back pain. (ECF No. 9, pp. 296-99). A physical examination of Plaintiff revealed moderate sacral midline tenderness and positive straight leg raises at sixty degrees, but musculoskeletal and neurological examinations revealed no abnormal findings. (ECF No. 9, pp. 298-99). Plaintiff was prescribed Acetaminophen-Hydrocodone and Prednisone for pain and inflammation. (ECF No. 9, p. 296).
The record does not indicate Plaintiff sought any further treatment until May 10, 2013, until he met with Dr. Wozniak to establish care. (ECF No. 9, pp. 320-21). Dr. Wozniak noted Plaintiff had not been taking any prescription pain medication for his back pain.
Plaintiff met with a neurologist, Dr. Sunghoon Lee, on August 1, 2013. (ECF No. 9, pp. 342-48). Physical examination of Plaintiff revealed no abnormal findings.
Plaintiff met with Dr. Ted Honghiran on June 9, 2014, for a general physical consultative examination at the request of Plaintiff's counsel. (ECF No. 9, pp. 349-55). Dr. Honghiran noted Plaintiff stated that his neurosurgeon in Harrison told him he did not need surgery and that Dr. Lee in Springfield told him he was too young for surgery and had advised him to lose weight. (ECF No. 9, p. 352). Dr. Honghiran also noted Plaintiff stated he was taking over the counter pain medication due to financial hardship.
The foregoing represents substantial evidence supporting the ALJ's RFC determination that Plaintiff was limited to the full range of sedentary work. Plaintiff's treatment was routinely conservative with multiple physicians recommending that he treat his pain with medication and weight loss and avoid surgery.
Plaintiff argues the ALJ failed to develop the record, specifically that the ALJ should have sought an RFC assessment from Dr. Honghiran. (ECF No. 13). The ALJ owes a duty to a claimant to develop the record fully and fairly to ensure his decision is an informed decision based on sufficient facts.
Plaintiff's argument that the ALJ failed to fully and fairly develop the record is without merit. Plaintiff's counsel requested the ALJ acquire a general physical consultative examination of Plaintiff. (ECF No. 9, p. 349). A general physical consultative examination is exactly what the ALJ asked Dr. Honghiran for, an "orthopedic exam with narrative report," which is what Dr. Honghiran provided. (ECF No. 9, p. 350). Plaintiff's counsel did not request the ALJ ask Dr. Honghiran to provide a Physical RFC Assessment. Nor was the ALJ required to request Dr. Honghiran provide a Physical RFC Assessment. The ALJ had before him the evaluations and treatment records of numerous healthcare providers which, as more specifically set forth above, provided sufficient evidence for the ALJ to make an informed decision regarding Plaintiff's alleged impairments. The Court also notes that other evidence in the record, including Plaintiff's own statements, constituted evidence regarding Plaintiff's limitations, and that the existing medical sources contained sufficient evidence for the ALJ to make a determination regarding Plaintiff's alleged impairments. The Court therefore finds the ALJ satisfied his duty to fully and fairly develop the record.
The Court notes that in determining Plaintiff's RFC, the ALJ considered the treatment notes and medical opinions of many treating physicians, and specialists, as well as those of the non-examining state agency consultants, and set forth the reasons for the weight given to the opinions.
C. Medical Vocational Guidelines:
The Medical-Vocational Guidelines, or Grids, "are a set of charts listing certain vocational profiles that warrant a finding of disability or non-disability."
Plaintiff argues the ALJ improperly relied on the Grids to direct his decision. Having determined the ALJ's RFC determination, that Plaintiff could perform the full range of sedentary work as defined by the regulation, was supported by substantial evidence in the record as a whole, it is clear that Plaintiff's RFC did not include nonexertional limitations that diminish or significantly limit Plaintiff's ability to perform the full range of Guideline-listed activities. I therefore find the ALJ was properly permitted to rely on the Medical-Vocational Guidelines to direct his finding that Plaintiff was not disabled during the relevant period.
Accordingly, having carefully reviewed the record, the undersigned finds substantial evidence supporting the ALJ's decision denying the Plaintiff benefits, and thus the decision is hereby affirmed. The undersigned further finds that the Plaintiff's Complaint should be, and is hereby dismissed with prejudice.
IT IS SO ORDERED.