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Schneider v. Astrue

November 24, 2009

GEORGE R. SCHNEIDER, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: McLAUGHLIN, Sean J., J.

MEMORANDUM OPINION

Plaintiff, George R. Schneider, commenced the instant action pursuant to 42 U.S.C. §§ 405(g) seeking judicial review of the final decision of the Commissioner of Social Security denying his application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. § 401 et seq. Plaintiff filed an application for DIB on July 11, 2005, alleging disability since May 4, 2001, due to diabetes, a fractured left hip, difficulty reading and alcoholism (Administrative Record, hereinafter "AR", 76-80; 92; 118). His application was denied, and he requested a hearing before an administrative law judge ("ALJ") (AR 49-50; 61; 63-67). Following a hearing held on September 13, 2007, the ALJ found that Plaintiff was not entitled to a period of disability or disability insurance under the Act (AR 20-43; 365-407). His request for review by the Appeals Council was denied (AR 6-12), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). The instant action challenges the ALJ's decision. Presently pending before the Court are cross-motions for summary judgment. For the reasons set forth below, the Plaintiff's motion will be denied and the Defendant's motion will be granted.

I. BACKGROUND

Plaintiff was born on May 29, 1952, and was 48 years old at the time of his alleged onset date and 55 years old on the date of the ALJ's decision (AR 76). At all times relevant to this case, he was an individual closely approaching advanced age within the meaning of 20 C.F.R. § 404.1563. Plaintiff did not finish high school, only attending through the 9th grade, but denied attending any special education classes (AR 97; 372). His past relevant work experience was as a press operator, fork lift operator and pallet maker (AR 41). He has not engaged in substantial gainful activity since May 4, 2001 (AR 372).

Plaintiff has a history of treatment for diabetes, vision problems and complaints of hip pain.*fn1 Early medical records show that Plaintiff was seen by George Vukmer, M.D., an ophthalmologist in August 2000 for a retinal check up (AR 165). Dr. Vukmer reported that Plaintiff's vision acuity seemed better and his visual acuity at that time was 20/30 in one eye and 20/50 in the other eye (AR 165). An eye examination in February 2001 revealed continued improvement and Dr. Vukmer found his visual acuity at that time was 20/25 in one eye and 20/40 in the other, and his peripheral vision was normal (AR 164). It was noted that Plaintiff had 20/20 vision with correction (AR 164).

In January 2002, Plaintiff was seen by Christopher Adsit, an optometrist, for complaints of blurry vision (AR 158-159). His visual acuity was 20/25 in the right eye and 20/60 in the left eye (AR 158-159). Dr. Adsit found his pupil examination was normal, as were his extraocular muscles and confrontation fields, and his color vision was intact (AR 158-159). Slit lamp examination showed some abnormal lenses bilaterally, but the remaining findings were normal (AR 23). Fundus examination showed some abnormality of the left optic nerve (AR 158-159). No diabetic retinopathy was reported (AR 158-159). Plaintiff did not return to Dr. Adsit until January 2003, and his vision examination was essentially unchanged (AR 154-157). Visual acuity was reported as 20/45 in the right eye and 20/65 in the left, and Plaintiff was prescribed corrective lenses (AR 154-157).

Plaintiff was also treated by Jeffrey Caldwell, M.D., beginning in January 2003. Dr. Caldwell noted that Plaintiff had a history of diabetes, but did not follow a special diet or exercise regimen (AR 197). Other than complaints of heartburn, Plaintiff had no other complaints (AR 197). Physical examination was normal and he was continued on the same medication with instructions to stop smoking (AR 197). Throughout 2003, the severity of the Plaintiff's diabetic condition fluctuated dependant upon his compliance with his prescribed medication regimen (AR 193-197; 212). His physical examinations remained essentially normal throughout the year (AR 193-197; 212).

When seen by Dr. Caldwell in January 2004, Plaintiff's physical examination was reported as normal and he was encouraged to abstain from alcohol (AR 191). In May 2004, Plaintiff's physical examination was normal, but lab results showed poor diabetic control (AR 190). Plaintiff was instructed on his diet and his medication was increased (AR 28).

Plaintiff was referred to Ann LaRochelle, M.D., a diabetic specialist in May 2004 (AR 257). Plaintiff reported that he had corneal implants, but had no musculoskeletal complaints or functional limitations (AR 28). Dr. LaRochelle adjusted his medication regimen, and subsequent lab results showed improvement in his diabetic condition (AR 257).

Plaintiff also returned to Dr. Adsit in May 2004 who found some optic disc edema, but attributed it to Plaintiff's elevated blood sugars (AR 152; 322). Dr. Adsit found no need for ocular treatment at that time, but noted that Plaintiff needed aggressive treatment for better diabetic control (AR 152;322).

When seen by Dr. LaRochelle in June 2004, Plaintiff reported feeling "shaky" and suffering from frequent episodes of hypoglycemia (AR 252-254). He acknowledged, however, that he did not test his blood sugar regularly (AR 252-254). Plaintiff also reported suffering from diabetic retinopathy and nocturia (AR 252-254). Dr. LaRochelle's reported findings on physical examination were unremarkable, with the exception of bilateral neuropathy in his feet (AR 252-254). Plaintiff was also seen at the Mind Body Wellness Center for diabetic education wherein he received instruction regarding lifestyle changes in order to manage his diabetes (AR 160). He was scheduled for a more in-depth meal planning appointment and encouraged to attend monthly support groups (AR 160).

Follow up notes from Dr. LaRochelle in July 2004 noted that Plaintiff's diabetic control was slipping and his medication regimen was changed, and by August laboratory studies showed some improvement (AR 251). Dr. Vukmer's progress notes from August 2004 showed that Plaintiff's visual acuity had improved, with prior reported blurriness attributed to his elevated blood sugars (AR 163; 316). Eye examination revealed visual acuity was 20/40 in one eye and 20/50 in the other eye, and there were no abnormalities noted (AR 163; 316). Dr. Vukmer noted the Plaintiff's "lousy self care" and he was again counseled and instructed to quit smoking (AR 163; 316).

Plaintiff returned to Dr. LaRochelle in October 2004, who noted that Plaintiff probably needed insulin (AR 249). In November 2004 Dr. LaRochelle's physical examination showed some numbness in the Plaintiff's feet, but there were no ulcers or pain (AR 248). Plaintiff refused to start insulin and Dr. LaRochelle continued his medications (AR 248).

When seen by Dr. Vukmer in December 2004, Plaintiff had no complaints, and his examination was unchanged from the previous visit (AR 162). Plaintiff was again instructed to take better self care (AR 162).

Plaintiff sought treatment in the emergency room in January 2005 as a result of his hand shaking and a "few seconds" of unresponsiveness (AR 169-170). Plaintiff reported a history of headaches, diabetes and stomach problems (AR 169-170). Plaintiff denied suffering from any shortness of breath, weakness or numbness in any area, vision changes or neurological symptoms (AR 169-170). Physical examination was normal and Plaintiff's lab studies were normal except for a slightly elevated glucose level and an elevated Prolactin level (AR 169-170). He was given Ativan and discharged in good condition (AR 169-170).

When seen by Dr. Caldwell in February 2005, physical examination revealed some tenderness in the liver and spleen area, as well as a hernia (AR 188). No other complaints were noted and his station and gait were normal (AR 188).

Plaintiff was also seen by Dr. LaRochelle in February 2005, who noted that his blood sugar readings were elevated and that while he generally followed his prescribed meal plan, he did not exercise and rarely monitored his blood sugar levels (AR 247). Plaintiff again refused to start insulin despite Dr. LaRochelle's recommendation that he do so (AR 247). In April 2005 Plaintiff complained of hyperglycemic and hypoglycemic episodes (AR 247). Plaintiff was instructed on the use of insulin and was able to give himself injections (AR 246). He was directed to check and document his blood sugar levels (AR 247). At his follow up appointment with Dr. LaRochelle in May 2005, Plaintiff reported that he was following the prescribed diet and checking his blood sugar regularly (AR 243). He denied any diabetic associated symptoms, and Dr. LaRochelle noted on his lab studies that he was doing better (AR 243; 278). She adjusted his medication regimen and further improvement was noted on lab studies in August (AR 278).

Plaintiff began treatment with the Conneaut Valley Health Center in August 2005. Plaintiff reported to Frank McLaughlin, D.O., a history of diabetes, left hip "rash", hearing loss, a hernia and cataracts (AR 172). No musculoskeletal complaints were noted, and his physical examination was normal, with ...


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