Angela Carrelli v. Comm'r of Social Security ( 2010 )

                               File Name: 10a0452n.06
                                               No. 09-6192                                   FILED
                                                                                          Jul 23, 2010
                              UNITED STATES COURT OF APPEALS                       LEONARD GREEN, Clerk
                                   FOR THE SIXTH CIRCUIT
    ANGELA KAY CARRELLI,                                     )
           Plaintiff-Appellant,                              )
                                                             )         ON APPEAL FROM THE
    v.                                                       )         UNITED STATES DISTRICT
                                                             )         COURT FOR THE EASTERN
           Defendant-Appellee.                               )                           OPINION
    BEFORE:        COLE and MCKEAGUE, Circuit Judges; MAYS, District Judge.*
           COLE, Circuit Judge. Plaintiff-Appellant Angela Carrelli seeks review of a district court’s
    decision affirming the decision of an administrative law judge (“ALJ”) who denied her request for
    social security disability benefits. Because substantial evidence supports the ALJ’s decision, we
                                           I. BACKGROUND
    A.     Factual background
           Carrelli is a high school graduate with an associate degree in nursing who previously worked
    as a registered nurse. In August 2004, she applied for disability insurance benefits and supplemental
    security income under Titles II and XVI of the Social Security Act, alleging that she had been unable
             The Honorable Samuel H. Mays, Jr., United States District Judge for the Western
    District of Tennessee, sitting by designation.
    No. 09-6192
    Angela Carrelli v. Commissioner of Social Security
    to work since August 25, 2001, because of right piriformis syndrome, shoulder problems, chronic
    pain, headaches, digestive tract problems, depression, anxiety, and difficulty sleeping. The state
    agency denied her application initially and on reconsideration. She then requested an administrative
    hearing. At the time of the hearing, she was fifty years old, and she was fifty-one years old when the
    ALJ issued his decision.
           1.      Medical evidence
           In August 2001, Carrelli sought treatment for pain in her right hip and was given a cortisone
    injection. The injection gave her temporary relief, but her pain persisted, and, in September 2001,
    she sought medical assistance from Dr. David Hauge. Dr Hauge performed a neurological
    evaluation, found “a very miniscule disc bulge at the L5-S1 level on the left which [was] very, very
    subtle.” (Administrative Record (“AR”) 187.) Dr Hauge suspected that Carrelli suffered from
    piriformis syndrome—a neuromuscular disorder that occurs when the piriformis muscle, a narrow
    muscle located in the buttocks, compresses or irritates the sciatic nerve. The following month, in
    November 2001, Carrelli received another cortisone injection. Before the procedure, an examination
    showed normal strength, sensation, and deep tendon reflexes in both legs. Post-procedure, Carrelli
    reported positive results and was instructed to return for injections as needed.
           In April 2002, still having hip pain, Carrelli underwent an electronyogram and a nerve-
    conduction study. The tests results were normal. Two months later, Carrelli consulted a pain
    specialist, Dr. Dennis Harris. His examination revealed that Carrelli had full range of motion and
    strength in her lower extremities, normal tone and movement, and the ability to walk on her heels
    and toes without difficulty. In addition, she had normal mood and affect as well as normal thought
    No. 09-6192
    Angela Carrelli v. Commissioner of Social Security
    content and thought process. Dr. Harris diagnosed chronic muscle pain and recommended
    aggressive physical therapy and epidural infusion. In August of that same year, Carrelli again saw
    Dr. Harris who administered an epidural infusion for her right hip. After the injection, she reported
    “good relief,” and that she was “able to tolerate physical therapy treatments which helped improve
    her range of motion.” (AR 210.)
            At a follow-up visit with Dr. Harris in October 2002, Carrelli reported that she thought she
    made “some progress” and was “slowly progressing” with physical therapy three times per week.
    (AR 254.) However, she also reported left hip pain and “expressed frustration” that “she would
    never get better.” (Id.) In addition, she requested another lower-back MRI. It showed only minor
    degenerative changes and a left-side disc bulge that was unchanged from previous MRIs.
            An MRI of Carrelli’s pelvis was taken several months later in February 2003. The MRI
    showed mild hypertrophy, or enlargement, of the right piriformis muscle, compared to the left. Dr.
    Glenn Jung, who read the MRI, concluded, however, that the “clinical significance of this [was]
    uncertain,” and “[t]here [were] no other significant findings.” (AR 520.) An August 2004 CT-scan
    of Carrelli’s pelvis showed no abnormalities. In addition, a bone mineral content exam in September
    2003 showed normal bone density in Carrelli’s lumbar spine and borderline ostepenia (low bone
    density) in her left hip. The radiologist recommended follow-up in two to three years. When
    Carrelli had the recommended follow-up in March 2006, the test showed only mild bone density loss
    in her left hip.
            During this time period, Carrelli also saw Dr. Paul Naylor, an orthopedic surgeon. In October
    2004, Dr. Naylor wrote to Carrelli’s attorney, explaining that Carrelli had chronic piriformis
    No. 09-6192
    Angela Carrelli v. Commissioner of Social Security
    syndrome and that he thought it was “not likely to get better.” (AR 279.) He also thought “with a
    reasonable degree of medical certainty she [was] not going to be able to carry on as an RN . . . .”
            In addition to hip pain, Carrelli began reporting left shoulder pain in April 2003. An MRI
    showed mild hypertrophy, which produced minimal impingement of her shoulder, but no evidence
    of a complete rotator cuff tear. In March 2004, after Carrelli had experienced pain in her left
    shoulder for more than one year, Dr. Naylor diagnosed her with chronic shoulder pain. Later that
    month, he performed an arthroscopic surgical procedure on her left shoulder. In June 2004, Carrelli
    reported marked improvement. However, in December 2004, Carrelli felt a “pop” in her left
    shoulder after lifting a twelve-pound turkey. Despite the injury, Dr. Naylor concluded that Carrelli
    had good range of motion, and an MRI showed only slight irritation.
            In January 2005, Dr. Jeffrey Summers, a consulting physician, examined Carrelli. Dr.
    Summers noted that Carrelli limped and favored her right leg but did not require an aid to walk. She
    also had mild difficulty rising from a seated position and getting on and off the examination table.
    Dr. Summers concluded that because of her hip pain, Carrelli would have difficulty sitting, standing,
    or walking for more than thirty minutes continuously or for more than six hours in a workday and
    would have difficulty squatting, kneeling, climbing, and stooping on a frequent basis. He also
    concluded, however, that she would otherwise be able to tolerate work-related activities in this
    regard. Because of her shoulder injury, Dr. Summers stated that Carrelli should avoid working
    overhead as well as reaching, pulling, pushing, lifting, or carrying greater than twenty pounds with
    her left arm, but otherwise, she should tolerate all other work-related activities in this regard.
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    Angela Carrelli v. Commissioner of Social Security
    Finally, Dr. Summers found Carrelli to be alert and oriented to person, place, time, and situation; he
    also found her cognitive function and intelligence to be commensurate with her formal education.
           A few months later, in January 2005, Dr. Celia Gulbenk, a state agency physician, reviewed
    Carrelli’s medical records. Dr. Gulbenk concluded that Carrelli could lift or carry up to twenty
    pounds occasionally and up to ten pounds frequently; was limited in her ability to push or pull with
    her lower extremities; could stand or walk for about six hours in an eight-hour workday; could sit
    about six hours in an eight-hour workday; and was limited to occasional climbing, balancing,
    stooping, kneeling, crouching, and crawling. The doctor also noted that Carrelli’s allegations of pain
    were not “wholly credible.” (AR 350.)
           During that same month, at the state agency’s request, psychologist Tracy Allred examined
    Carrelli. Dr. Allred noted that Carrelli suffered a “mixture of depression and anxiety symptoms due
    to circumstantial stresses in her life.” (AR 340.) As a result, Dr. Allred found it difficult to
    differentiate mental health symptoms from medical symptoms. In addition, when questioned about
    prior mental health treatment, Carrelli was “not interested,” denied current treatment, and denied
    taking any medication for mental health symptoms. (AR 338.) Dr. Allred and Carrelli discussed
    Carrelli’s use of Lorazepam, but Carrelli insisted that it was prescribed for “other medical uses
    versus depression or anxiety.” (AR 339.) Ultimately, Dr. Allred diagnosed anxiety and opined that
    Carrelli was moderately limited in her ability to understand and remember, to sustain concentration
    and persistence, to interact socially, and to adapt and tolerate work-related stress.
           During the next month, February 2005, Dr. Larry Welch, a state agency reviewing
    psychologist, agreed with Dr. Allred’s conclusions and further opined that Carrelli could understand,
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    Angela Carrelli v. Commissioner of Social Security
    remember, and complete detailed tasks on a regular and continual basis with occasional difficulty
    sustaining concentration, persistence, and pace. He also concluded that she could interact with
    others without difficulty, could adapt to a routine but not to frequent or fast-paced change, and could
    set and achieve most long-range goals with only occasional assistance.
            That summer, in July 2005, neurologist Dr. Jack Scariano examined Carrelli. He noted that
    she was oriented to person, place, and time and that her mood and affect were appropriate to the
    situation. Her speech was appropriate and her recent and remote memory were intact. Her attention
    span and concentration were good as were her vocabulary, awareness of current events, and past
    history. Carrelli’s touch, pin, and vibratory sensations were normal; she had full strength in all
    extremities; her balance was normal; and she had a normal gait, with normal heel-toe and tandem
    walking. She did, however, show marked spasms in her right piriformis muscles. Dr. Scariano
    diagnosed piriformis syndrome and recommended injections to relieve the pain.
            The next year, in March 2007, Carrelli underwent piriformis-release surgery with Dr. Naylor.
    Piriformis-release surgery involves cutting the tendon of the muscle to relax it. At a follow-up visit
    two weeks later, Dr. Naylor noted that Carrelli’s wound was healing and that she was “ambulating
    well.” (AR 675.) Prior to the procedure, Dr. Naylor had completed a “Medical Source Statement
    of Ability to Do Work-Related Activities,” in which he opined that Carrelli could not lift any weight;
    could not stand or walk at all; could not sit at all; was limited in her ability to push and pull her lower
    extremities; and could never climb, balance, kneel, crouch, crawl, or stoop.
            In addition to specialists, Carrelli saw a general practitioner, Dr. Mancel Wakham, from
    September 2001 until November 2006. During that period, Dr. Wakham treated Carrelli for her hip
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    Angela Carrelli v. Commissioner of Social Security
    and shoulder injuries as well as other medical issues not related to this appeal. He referred her to
    specialists, regularly prescribed pain medications, and prescribed sleep aids and medications used
    to treat anxiety. In December 2003, Dr. Wakham wrote a brief letter opining that Carrelli’s “medical
    disabilities are permanent in nature. Her physical limitations keep her from performing duties as a
    registered nurse or any other gainful employment.” (AR 65.) Three years later, in December 2006,
    Dr. Wakham completed a “Medical Source Statement of Ability to Do Work-Related Activities,”
    and opined that Carrelli could not lift any weight; could not stand or walk at all; could not sit at all;
    was limited in her ability to push or pull in her lower extremities; and could never climb, balance,
    kneel, crouch, crawl, or stoop.
            2.      Physical therapy
            Carrelli attended a series of physical therapy sessions for her right hip and left shoulder from
    May 2002 through November 2006. During these sessions, she set goals for herself and charted her
    progress. At an initial evaluation in April 2003, for instance, Carrelli’s goals for the next four weeks
    of therapy included tolerating walking greater than 1.5 hours with decreased pain medication and
    increasing “overall functional status to allow her to drive a car and eventually return to work.” (AR
    600.) At a November 2004 initial evaluation, Carrelli reported that she was doing “fairly well” after
    her rotator cuff surgery. (AR 563.) She also reported continued pain in her right buttock, which left
    her unable to drive for long periods of time. Despite the pain, however, she continued to walk at a
    local track. At an initial evaluation in February 2006, Carrelli reported that she was having difficulty
    sitting or standing for long periods of time and that she could not sit for longer than one minute
    without have to shift positions.
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    Angela Carrelli v. Commissioner of Social Security
    B.     Procedural history
           1.      Administrative hearing
           An administrative hearing was held in May 2007. At the hearing, Carrelli testified that her
    hip was her most significant medical problem. She explained that she experienced spasms in her
    back, buttocks, and leg; had to change positions frequently; and could not sit for more than five
    minutes at a time. She further explained that she could stand for an hour or two but then needed to
    rest. She described her second most serious problem as concentration, explaining that her lack of
    focus was related to how much attention she had to pay to the pain and the dosage of medication
    needed to control the pain. When asked by the ALJ if she had anxiety or depression, she testified
    that she had more anxiety than depression but was not seeking treatment for her anxiety. Carrelli
    also testified that she had been taking continuing education courses for nursing; had a driver’s
    license and had driven in the past month; liked to read; did stretching exercises every morning; and
    tried to walk at a track three times per week. Finally, she stated that she took an hour-long bath
    every night to relax her muscles.
           Next, the ALJ asked a vocational expert (“VE”) what work was available for a person of
    Carrelli’s age, education, and vocational background, who was able to perform light work with a sit-
    stand option; no pushing or pulling or leg controls with the right leg; only occasional lifting and
    carrying with the left arm; no climbing or crawling; and only occasional stopping or bending. The
    VE responded that such a person could not perform Carrelli’s past work as a registered nurse but
    could perform other jobs such as a medical unit clerk, a medical companion, or a general clerk. The
    VE explained that medical companion jobs involve no lifting but entail sitting with an ill person,
    No. 09-6192
    Angela Carrelli v. Commissioner of Social Security
    monitoring her position, and notifying other personnel if assistance is required. Later, Carrelli’s
    attorney asked whether a person could perform medical unit clerk work if the person had difficulty
    remaining alert or was easily distracted. The VE responded that it would depend on the severity of
    those limitations. Carrelli’s attorney also asked the VE if a person who missed more than two days
    of work per month was employable; the VE responded that “[g]enerally, over two absences,
    consistently, per month, is the cutoff point.” (AR 755.)
           In addition to the testimony offered during the administrative hearing, a surveillance tape of
    Carrelli was admitted as part of the record. The tape is also evidence in litigation between Carrelli
    and a private disability insurer. The tape was submitted at the ALJ’s request.
           2.      The ALJ’s decision
           The ALJ found that Carrelli had severe impairments of right piriformis syndrome, with
    piriformis-release surgery in March 2007; history of left shoulder impingement syndrome, with left
    shoulder arthroscopy and rotator cuff repair in March 2004; and minimal disc bulging in her lower
    back. The ALJ also found that Carrelli does not have a severe mental impairment. The ALJ then
    concluded that Carrelli’s physical impairments limited her to a restricted range of light work with
    a sit-stand option. The ALJ further found, based on the VE’s testimony, that there were jobs Carrelli
    could perform, such as medical unit clerk, medical companion, and general clerk.
           3.      District court’s decision
           Pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), Carrelli timely filed a civil action in the
    United States District Court for the Eastern District of Tennessee for review of the ALJ’s decision.
    The magistrate judge found there was substantial evidence for the ALJ’s decision and recommended
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    Angela Carrelli v. Commissioner of Social Security
    affirming. The district court agreed and adopted the magistrate judge’s report and recommendation.
           Carrelli timely appealed.
                                              II. ANALYSIS
    A.     Standard of review
           Under 42 U.S.C. § 405(g), our review of the Commissioner’s decision is limited to
    determining whether the factual findings are supported by substantial evidence and whether the
    correct legal standards were applied. See Cutlip v. Sec'y of Health & Human Servs., 
    25 F.3d 284
    286 (6th Cir. 1994). Substantial evidence means “more than a scintilla of evidence but less than a
    preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support
    a conclusion.” Id. We may not try the case de novo, resolve conflicts in evidence, or decide
    questions of credibility. Walters v. Comm’r of Soc. Sec., 
    127 F.3d 525
    , 528 (6th Cir. 1997). If
    supported by substantial evidence and decided under the correct legal standard, the Commissioner’s
    decision must be affirmed even if this Court would decide the matter differently, and even if
    substantial evidence also supports the claimant’s position. Mullen v. Bowen, 
    800 F.2d 535
    , 545 (6th
    Cir. 1986) (en banc).
    B.     Legal framework for evaluating disability claims
           “The plaintiff has the ultimate burden to establish an entitlement to benefits by proving the
    existence of a disability . . . .” Wyatt v. Sec’y of Health & Human Servs., 
    974 F.2d 680
    , 683 (6th Cir.
    1992). The Social Security Administration defines a “disability” as an “inability to engage in any
    substantial gainful activity by reason of any medically determinable physical or mental impairment
    which can be expected to result in death or which has lasted or can be expected to last for a
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    Angela Carrelli v. Commissioner of Social Security
    continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To make a determination
    as to disability, an ALJ undertakes a five-step sequential evaluation mandated by regulation. Wilson
    v. Comm’r of Soc. Sec., 
    378 F.3d 541
    , 548 (6th Cir. 2004). First, the claimant must demonstrate that
    she has not engaged in substantial gainful activity during the claimed period of disability. 20 C.F.R.
    § 404.1520(a)(4)(i). Second, the claimant must show that she suffers from a severe medically
    determinable physical or mental impairment. § 404.1520(a)(4)(ii). Third, if the claimant shows that
    her impairment meets or medically equals one of the impairments listed in 20 C.F.R. pt. 404, Subpt.
    P, App. 1, she is deemed disabled. § 404.1520(a)(4)(iii). If not, the ALJ fourth determines whether,
    based on the claimant’s residual functioning capacity (“RFC”), the claimant can perform her past
    relevant work, in which case the claimant is not disabled. § 404.1520(a)(4)(iv). If so, the ALJ fifth
    determines whether, based on the claimant’s RFC, as well as her age, education, and work
    experience, the claimant can make an adjustment to other work, in which case the claimant is not
    disabled. § 404.1520(a)(4)(v). The claimant bears the burden of proof during the first four steps,
    but the burden shifts to the Commissioner at step five. Wilson, 378 F.3d at 548 (citing Walters, 127
    F.3d at 529). To prevail at step five, the Commissioner must identify a significant number of jobs
    in the economy that accommodate the claimant’s RFC and vocational profile. Jones v. Comm’r of
    Soc. Sec., 
    336 F.3d 469
    , 474 (6th Cir. 2003).
           Carrelli argues that the ALJ erred in two ways. First, she claims the ALJ erred at step two
    by finding that her anxiety disorder was not a severe impairment. Second, she argues that the ALJ
    erred at step five by concluding that she was capable of making a successful adjustment to other
    work and that such work is available.
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    Angela Carrelli v. Commissioner of Social Security
    C.     Step two: severe mental impairment
           At step two, Carrelli must show that she suffers from a severe medically determinable
    physical or mental impairment. 20 C.F.R. § 404.1520(a)(4)(ii). An impairment is not considered
    severe when it “does not significantly limit [one’s] physical or mental ability to do basic work
    activities.” § 404.1521(a).
           Relying on the opinions of Dr. Allred and Dr. Welch, Carrelli argues that the ALJ failed to
    take account of her severe mental impairments. As we have discussed, Dr. Allred concluded that
    Carrelli presented a “mixture of depression and anxiety symptoms.” (AR 342.) However, Dr. Allred
    found it difficult to determine the cause of Carrelli’s anxiety—whether it was caused by mental-
    health symptoms or medical symptoms—because of the “circumstantial stresses” in Carrelli’s life.
    (AR 342.) In addition, although Dr. Allred concluded that some of Carrelli’s mental abilities were
    limited due to anxiety, Dr. Allred further concluded that Carrelli was only “moderately limited.”
    (AR 340.) Dr. Welch came to a similar conclusion. He opined that Carrelli could understand,
    remember, and complete detailed tasks on a regular and continual basis with only “occasional”
    difficulty sustaining concentration, persistence, and pace. (AR 353.) We consequently conclude
    that, although Dr. Allred’s and Dr. Welch’s diagnoses might—with additional evidence—support
    the conclusion that Carrelli suffers a severe mental impairment, they do not necessarily lead to that
           Carrelli also relies on her history of using psychotropic drugs, including Ativan, Lorazepam,
    Zoloft, Cymbalta, and Ritalin, as evidence of her mental impairments. Unfortunately for her, use
    of such drugs is not necessarily indicative of a severe mental impairment. See Thacker v. Sec’y of
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    Angela Carrelli v. Commissioner of Social Security
    Health & Human Servs., No. 90-5546, 
    1990 U.S. App. LEXIS 21866
    , at *7 (6th Cir. Dec. 12, 1990)
    (“The mere fact that claimant is taking medication to calm his nerves does little to establish mental
    impairment.”). Moreover, the record indicates that these drugs were prescribed for sedation, muscle
    spasms, and sleeping. In fact, Carrelli told Dr. Allred that she used Lorazepam (commonly used to
    treat anxiety), not for depression and anxiety, but for other medical purposes. Thus, her reliance on
    her psychotropic drug-use falls short of conclusively demonstrating a severe mental impairment.
           Moreover, there is evidence on the other side of the scale supporting the ALJ’s determination.
    First, other doctors reported that Carrelli suffered no mental impairments. Neurologist Dr. Scariano
    concluded that Carrelli had “no significant affect distress, memory or concentration problems, or
    problems with insight and judgment.” (AR 376-77.) Dr. Summers also observed that Carrelli was
    alert and oriented to person, place, time, and situation; her cognitive function and intelligence were
    commensurate with her formal education; and she interacted well with him, with no abnormal
    behaviors or mannerisms. Second, Carrelli’s claims that she had difficulty concentrating and could
    not follow a newspaper were inconsistent with her own testimony that she takes continuing education
    classes to maintain her nursing license, cares for her teenage son, prepares simple meals, enjoys
    reading, and drives. Third, the record shows that Carrelli has not sought treatment for her alleged
    mental impairments. Although not dispositive, treatment that a claimant has received is a relevant
    factor in evaluating the alleged intensity and persistence of her symptoms. See 20 C.F.R. §
    404.1529(c)(3)(v). Finally, Carrelli herself attributes much of her anxiety to her physical condition.
    During the administrative hearing, she testified that the anxiety and depression that she suffers is
    related to pain. This self-assessment supports the ALJ’s conclusion that Carrelli’s anxiety was a
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    Angela Carrelli v. Commissioner of Social Security
    symptom of her physical impairment and not a separate disorder.
            In the final analysis, we conclude that substantial evidence supported the ALJ’s conclusion
    that Carrelli does not suffer from a severe mental impairment.
    D.      Step five: successful adjustment to other available work
            Carrelli also challenges the ALJ’s conclusion that there were jobs available that Carrelli
    could perform. She launches this attack in three ways. First, she claims that the ALJ was
    predisposed to find against her. In other words, she claims he was biased. Next, she argues that the
    ALJ improperly ignored the opinions of her treating physicians. Finally, she claims that the ALJ
    devised inaccurate hypothetical questions.
            1.      Bias
            We apply the “presumption that policymakers with decisionmaking power exercise their
    power with honesty and integrity,” and “any alleged prejudice must be evident from the record and
    cannot be based on speculation or inference.” Navistar Int’l Transp. Corp. v. U.S. EPA, 
    941 F.2d 1339
    , 1360 (6th Cir. 1991). In addition, any claim of bias must be supported by a “strong showing”
    of bad faith. City of Mount Clemens v. U.S. EPA, 
    917 F.2d 908
    , 918 (6th Cir. 1980) (internal
    quotation marks omitted). Carrelli has offered no evidence to meet this high standard, and we easily
    reject her assertion.
            2.      Treating physicians’ opinions
            As discussed, both Dr. Wakham and Dr. Naylor wrote letters and completed evaluation forms
    opining that Carrelli’s ability to work was highly limited. Carrelli claims that the ALJ completely
    disregarded these opinions, but she misreads the decision. Contrary to her accusation, the ALJ did
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    Angela Carrelli v. Commissioner of Social Security
    not disregard the doctors’ opinions; instead, the ALJ concluded that the opinions “grossly
    exaggerat[ed]” Carrelli’s limitations, and the “ridiculously oppressive limitations” were inconsistent
    with the objective evidence of the record, clinical exam notes, Carrelli’s reported daily activities, and
    the ALJ’s observations of her at the administrative hearing. (AR 18, 21.) Thus, the ALJ did not
    disregard the opinions—he simply found them unpersuasive.
            Carrelli also argues that the opinions of her treating physicians should have been given
    controlling weight. She is correct that an ALJ generally should give greater deference to a treating
    physician’s opinion than to a non-treating physician’s opinion. See Blakley v. Comm’r of Soc. Sec.,
    581 F.3d 399
    , 406 (6th Cir. 2009) (applying the treating-physician rule). However, an ALJ “must”
    give a treating source controlling weight only if it is “well-supported by medically acceptable clinical
    and laboratory diagnostic techniques” and is “not inconsistent with other substantial evidence in [the]
    case record.” 20 C.F.R. § 404.1527(d)(2); see also Blakley, 581 F.3d at 406. Indeed, “‘[i]t is an
    error to give an opinion controlling weight simply because it is the opinion of a treating source . .
    . if it is inconsistent with the other substantial evidence in the case record.’” Id. (quoting Soc. Sec.
    Rul. 96-2p, 1996 SSR LEXIS 9, at *5 (July 2, 1996)) (alteration in original). If, however, the ALJ
    does not accord controlling weight to a treating physician, the ALJ still must determine how much
    weight is appropriate by considering the record as a whole. Wilson, 378 F.3d at 544; see also 20
    C.F.R. § 404.1527(d)(4) (“Generally the more consistent an opinion is the with the record as whole,
    the more weight we will give that opinion.”); 20 C.F.R. § 404.1527(b) (“In deciding whether you
    are disabled we will always consider the medical opinions in your case record together with the rest
    of the relevant evidence we receive.”).
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    Angela Carrelli v. Commissioner of Social Security
           The ALJ did that here. The ALJ first noted that the MRIs showed only “very miniscule”
    lower back disc bulging with no nerve root impingement, mild hypertrophy of the piriformis muscle,
    and a shoulder strain after holding a twelve pound turkey with only her left arm. (AR 18.) The ALJ
    then noted that Carrelli’s pain decreased after her piriformis release surgery in March 2007, and that
    after her shoulder surgery in March 2004, she had good range of motion and only minimal
    tenderness. (Id.) The ALJ further noted the numerous diagnostic tests showing no physical or
    neurological abnormalities, including CT-scans, EMGs, MRIs, and nerve-conduction studies. (Id.)
    The ALJ then relied on Dr. Summers’s finding that Carrelli had no neurological or musculosketal
    abnormalities, along with his assessment that Carrelli could lift twenty pounds and sit, stand, or walk
    for up to six hours, but no more than thirty minutes at a time. (AR 19.) The ALJ explained that he
    gave “considerable weight” to Dr. Summers’s assessment because the assessment took account of
    Carrelli’s left shoulder and hip pain but also was consistent with the benign diagnostic tests and
    Carrelli’s reported and observed daily activities. (Id.) Moreover, as the ALJ noted, Dr. Gulbenk,
    an expert in Social Security disability evaluation, agreed with Dr. Summers’ assessment. (Id.)
           Consequently, we conclude that the opinions of Dr. Wakham and Dr. Naylor were
    inconsistent with the record as a whole, and the ALJ was not required to defer to their opinions.
           3.      Hypothetical questions
           Finally, Carrelli argues that the questions the ALJ posed to the VE did not accurately portray
    her mental and physical impairments. See Varley v. Sec’y of Health & Human Servs., 
    820 F.2d 777
    779 (6th Cir. 1987). In particular, she claims that none of the hypothetical questions took account
    of her mental impairments requiring the use of psychotropic drugs, the number of frequent absences
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    Angela Carrelli v. Commissioner of Social Security
    that her impairments would cause, and her need to be able to sit and stand at will. Carrelli further
    contends that when the VE considered these additional limitations, the VE testified that no jobs
    would be available for Carrelli.
           An ALJ’s hypothetical question to a VE must accurately portray a claimant’s physical and
    mental impairments, but it is also “well established that an ALJ may pose hypothetical questions to
    a vocational expert and is required to incorporate only those limitations accepted as credible by the
    finder of fact.” Casey v. Sec’y of Health and Human Servs., 
    987 F.2d 1230
    , 1235 (6th Cir. 1993).
    Here, our review of the record reveals that the ALJ properly incorporated his findings into the
    determination of Carrelli’s RFC. The ALJ then presented Carrelli’s RFC, along with her age,
    education, and past relevant work experience to the VE in hypothetical questions. The VE
    subsequently concluded that a number of jobs that Carrelli was able to perform existed.
           Carrelli is correct that the VE testified that the identified jobs would be eliminated for a
    person who had difficulty remaining alert or for a person who was easily distracted, and the VE also
    testified that an employee with frequent absences would have trouble maintaining employment. But
    consideration of these additional factors is beside the point. When asked a hypothetical question
    encompassing the limitations that the ALJ found credible, the VE testified that jobs existed. The
    additional limitations offered by Carrelli’s attorney—limitations that the ALJ found not
    credible—need not be considered. We therefore reject Carrelli’s challenge.
                                           III. CONCLUSION
           For the foregoing reasons, we AFFIRM the judgment of the district court.
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