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Huth v. Astrue

January 15, 2010

JESSICA LYNN HUTH, 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, Jessica Lynn Huth, commenced the instant action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security, who found that she was not entitled to supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. Plaintiff filed an application for SSI on March 3, 2005, alleging disability since October 1, 2004 due to herniated discs, anxiety and depression (Administrative Record, hereinafter "AR", at 15; 54-55). Her application was denied and she requested a hearing before an administrative law judge ("ALJ") (AR 41-45; 47). A hearing was held on May 1, 2007 and on September 26, 2007, the ALJ found that Plaintiff was not disabled at any time through the date of his decision, and therefore was not eligible for SSI benefits (AR 15-22; 262-281). Plaintiff's request for review by the Appeals Council was denied (AR 4-7), 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 Defendant's motion will be granted and the Plaintiff's motion will be denied.

I. BACKGROUND

Plaintiff was born on April 5, 1974 and was 33 years old on the date of the ALJ's decision (AR 21). She is a high school graduate and has past relevant work experience as a hostess/cashier, laborer/stocker and telemarketer (AR 21; 55). Plaintiff has claimed disability due to both mental and physical impairments.

Plaintiff began treatment with Bradley Fell, M.D. at the Seneca Medical Center on October 9, 2003 (AR 201). She stated that she was depressed, fatigued, stressed, irritable, tearful and had hateful thoughts (AR 201). She reported low self-esteem and problems with concentration and decision making (AR 201). Plaintiff also complained of some numbness in her lower extremities (AR 201). Dr. Fell assessed her with fatigue and obesity and discussed diet, exercise and surgery options (AR 200). He encouraged her to follow a good diet and engage in regular exercise (AR 200). He prescribed Lexapro for her complaints of depression (AR 200).

At an intake interview on January 20, 2004 through the Venango County MH/MR Administration, Plaintiff reported a history of abuse from her mother and a history of several destructive relationships (AR 227). She lived with her two children and was unemployed (AR 227). Plaintiff indicated that she loved her most recent job and wished she had stayed at that job. (AR 228). At the time of the evaluation she was taking math and computer courses through the New Choices program and enjoyed all types of arts and crafts (AR 228). She complained of depression and difficulty concentrating (AR 229). The interviewer recommended that she undergo a psychiatric evaluation and individual outpatient therapy (AR 230).

Plaintiff returned to Dr. Fell on February 25, 2004 and reported numbness down her left leg and arm (AR 199). She reported that her weight caused her a lot of problems (AR 199). Plaintiff informed Dr. Fell that the Lexapro had not helped her symptoms of depression, but that she did not want him to treat her symptoms; rather, she had an appointment with the Regional Counseling Center for treatment (AR 198). Dr. Fell ordered x-rays of her cervical and lumbar spine and advised her to watch her diet (AR 198).

On April 6, 2004 Plaintiff continued to complain of left arm and leg numbness (AR 196). She was reluctant to discuss her weight, and Dr. Fell noted she was "avoidant" and would not talk much during the visit (AR 196). On April 14, 2004, an MRI of the Plaintiff's lumbar spine revealed a small broad based central disc herniation at the L4-L5 level causing mild impingement upon the mid anterior thecal sac, but no significant foraminal narrowing was identified (AR 111). An MRI of her cervical spine on the same date revealed normal spinal alignment, normal bone marrow signal intensity and a normal spinal cord (AR 112). At the C5-C6 level, there was very minimal disc bulging, but no formaminal or spinal canal narrowing (AR 112). Plaintiff complained of severe back pain on April 23, 2004 and Dr. Fell prescribed Effexor (AR 195).

Plaintiff attended seven physical therapy sessions from May 6, 2004 through June 16, 2004 for her complaints of lower back pain. Discharge notes reflect that Plaintiff's goals were only partially attained and that she was discharged from therapy due to non-attendance (AR 114).

Plaintiff underwent a psychiatric evaluation performed by David Fontaine, D.O. from the Regional Counseling Center on May 12, 2004 (AR 218-219). Plaintiff reported a history of depression and anxiety (AR 218). Plaintiff further reported a number of emotionally devastating relationships (AR 218). On mental status examination, Dr. Fontaine reported that Plaintiff's affect was bland and she expressed feelings of hopelessness, helplessness and loneliness, but she spoke in a clear and concise fashion, there was no evidence of hallucinations or delusions, her memory was intact, her fund of knowledge was quite good, her insight was reasonably good and her judgment was intact (AR 218). Dr. Fontaine diagnosed her with dysthymia versus major depression, severe, recurrent; mild anxiety disorder; mixed personality traits; and obesity (AR 218). He assessed her with a current and past year Global Assessment of Functioning ("GAF") score of 60 and prescribed Xanax (AR 218).*fn1

Plaintiff returned to Dr. Fell on June 24, 2004 for follow-up (AR 193). She inquired about bariatric surgery and reported that her physical therapy regimen had not helped (AR 193). She complained of foot and ankle pain, back pain and increased depression (AR 193). Dr. Fell prescribed a different physical therapy program and referred her to a podiatrist (AR 193).

On July 26, 2004, Plaintiff complained of increased muscle spasms, neck pain and back pain (AR 191). Dr. Fell diagnosed her with back pain, herniated disc at L4-5 and degenerative joint disease of the cervical spine (AR 191). He prescribed Skelaxin, Naprosen and a heating pad for her complaints of pain (AR 191). He also prescribed an exercise program at Curves (AR 191).

Plaintiff attended three physical therapy sessions from August 4, 2004 through September 9, 2004 (AR 100). Her pain had reportedly decreased significantly by her last session (AR 100). Plaintiff's strength was 4/5 throughout, her cervical range of motion was within normal limits and her lumbar range of motion was within normal limits, with the exception of some limited side bending and bilateral rotation (AR 100). Discharge notes reflect that Plaintiff's goals were again not met because she "did not attend physical therapy due to having too busy of a schedule and having too much going on at [that] time" (AR 100).

Plaintiff was evaluated by Anita Courcoulas, M.D. for bariatric surgery on September 13, 2004 (AR 188-189). Dr. Courcoulas reported that the Plaintiff was morbidly obese with a body mass index of 50 (AR 190). Dr. Courcoulas recommended she undergo a preoperative work up to include sleep studies, an upper GI study, and a nutrition and psychological evaluation (AR 190). Plaintiff understood the risks of the surgery and elected to pursue the preoperative work up (AR 190).

On October 5, 2004, Plaintiff reported to Dr. Fell that she intended to follow through with gastric bypass surgery for her obesity (AR 187). She was assessed with back pain and obesity, referred to physical therapy and given Skelaxin samples (AR 187). On October 20, 2004 Plaintiff reported suffering from "extreme" lower back pain after she "overworked" herself (AR 186). Dr. Fell prescribed Ultram and referred her to a pain clinic (AR 186).

Plaintiff attended five physical therapy sessions between October 18, 2004 and November 15, 2004 (AR 88). It was reported that goals were not met secondary to the Plaintiff's limited attendance (AR 88). Plaintiff was discharged on November 22, 2004 after she contacted the facility and informed them that she would not be continuing therapy (AR 88).

On November 18, 2004, Plaintiff was seen by Dr. Fell and complained of acid reflux (AR 184). Plaintiff requested that he complete the necessary forms for gastric bypass surgery (AR 184). She was assessed with obesity, back pain, anxiety/depression and GERD, and was provided samples of Protonix (AR 184).

Plaintiff returned to Dr. Fontaine at the Regional Counseling Center on November 24, 2004, who reported she was doing well on her medication (AR 221).

On December 3, 2004, Plaintiff telephoned Dr. Fell's office requesting a permission slip to use the exercise equipment at the YMCA; Dr. Fell signed a permission slip stating she could engage in activity as tolerated (AR 182).

On December 12, 2004, Albert Scott, Ed.D., performed a neuropsychological evaluation in order to establish a diagnosis and formulate treatment goals (AR 82-85). Her dates of consultation with Dr. Scott were October 20, 2004, October 29, 2004 and November 16, 2004 (AR 82). Plaintiff reported that she had been kicked in the head by a deer at age 13 and lost consciousness (AR 83). Plaintiff further reported a previous psychiatric hospitalization for a suicide attempt as a teenager (AR 82-83). Dr. Scott noted that she was obsessed with having gastric bypass surgery (AR 83). She complained of suffering from sleep and appetite problems, anxiety, depression, difficulty making decisions and social withdrawal, as well as violent behavior and suicidal thoughts in the past (AR 83). Plaintiff also complained of back and neck pain, which was exacerbated by excessive lifting or stressful activity (AR 83). Her medication regimen consisted of Zanax, Naproxen and Skelaxin (AR 83).

Dr. Scott administered a number of psychological tests, noting that at times during testing Plaintiff was hostile and aggressive (AR 83). Test results from the Wechsler Memory Scale-Third Edition (WMS-III) revealed problems with her working memory, and Rorschach Inkblot Procedure (RIP) results were indicative of paranoia, post traumatic stress disorder, an affective disorder and psychosis (AR 84). Plaintiff scored in the average range for receptive vocabulary and expressive vocabulary (AR 83).

Dr. Scott recommended that Plaintiff undergo a neurological evaluation, as well as an EEG, MRI and SPECT studies (AR 85). He recommended she thereafter be referred to a psychiatrist for her "numerous" psychiatric problems, and that she undergo drug and alcohol counseling, mental health counseling, trauma therapy and anger management classes (AR 85). Dr. Scott opined that "[w]ithin a reasonable degree of professional certainty" Plaintiff was "psychiatrically disabled" and that "numerous issues" needed to be resolved before she underwent gastric bypass surgery (AR 85).

Plaintiff returned to Dr. Fell on January 10, 2005 and reported that she was doing well and had lost weight, going from 267 pounds to 254 pounds (AR 180). Dr. Fell advised her to continue ...


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