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Coccarelli- Yacobozzi v. Astrue

February 9, 2010


The opinion of the court was delivered by: Sean J. McLaughlin United States District Judge


McLaughlin, Sean J., District Judge.

I. Introduction

Terri Coccarelli-Yacobozzi, ("Plaintiff") 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, ("Commissioner"), denying her claims for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §401, et. seq. and §1381, et. seq. Plaintiff filed an application for DIB with a protective filing date of March 23, 2004. (AR. at 67).*fn1 Her application was denied by the Commissioner on September 8, 2004. (AR. at 44). Plaintiff filed a timely request for an administrative hearing on October 8, 2004. (AR. at 49-50). She then protectively filed an application for SSI on July 12, 2006. (AR. at 20). Plaintiff alleged disability as a result of mixed bi-polar disorder, depression and neck and back pain, with an alleged onset date of September 1, 2002. (AR. at 44, 323).*fn2

An administrative law judge ("ALJ") conducted two hearings, on September 21, 2006 and May 15, 2007. (AR. at 291-302; 303- 332). Plaintiff appeared at both hearings, represented by counsel, and testified. (AR. at 291-332). Additionally, vocational experts appeared at both hearings and testified in regard to the availability of work for an individual with Plaintiff's limitations. Id.

The ALJ issued a decision on August 17, 2007, finding that Plaintiff was not disabled within the meaning of the Social Security Act. (AR. at 20-31). The Appeals Council denied Plaintiff's request for review of the ALJ's determination on September 24, 2008, (AR. at 5-8), making the ALJ's decision the final determination of the Commissioner. Having exhausted her administrative remedies, Plaintiff filed a timely Complaint against the Commissioner in this Court, seeking judicial review of the final determination of the Commissioner. (Doc. No. 3). Presently pending before the Court are the parties' cross motions for summary judgment. (Docs. No.8-11).

For the following reasons, Plaintiff's Motion for Summary Judgment, (Doc. No. 8), will be denied and the Commissioner's Motion for Summary Judgment, (Doc. No. 10), will be granted.

II. Background

Plaintiff was born on July 27, 1959, making her forty-seven (47) years old at the time of the second administrative hearing in May 2007. (AR. at 307). She testified that she has a high school education and additional training as a nurse's aide. Id. Her prior work experience includes experience as a certified nurse's assistant at a nursing home, (AR. at 307-308), housekeeper, (AR. at 308), a cashier at a fast-food restaurant, (AR. at 309), and a cashier at a hardware store. (AR. at 314). At the time of the second administrative hearing, Plaintiff testified that she had been recently married and lived with her husband. (AR. at 306).

The administrative record indicates that Plaintiff was treated by numerous physicians for both physical and mental health problems as early as 2002. (AR. at 128-284).

Hamot Medical Center

The earliest records in the transcript from Hamot Medical Center indicate that Plaintiff was admitted to the hospital on January 27, 2000 after she ingested an overdose of medication in an attempted suicide. (AR. at 127). She remained in the hospital until January 31, 2000. Id. She was treated with and prescribed Celexa*fn3 and Depakote.*fn4 She was diagnosed as having bipolar affective disorder, depressive phase, a history of cocaine, prescription analgesic and stimulant abuse, personality disorder as well as a history of chronic back pain and migraine headaches. (AR. at 128). At the time she was admitted to the hospital, Plaintiff was assigned a Global Assessment of Functioning ("GAF") score of 55. (AR. at 134).*fn5

Stairways Behavioral Health

Dr. Helen Kohn performed a psychiatric evaluation of Plaintiff on June 29, 2004. (AR. at 194). At the time of the evaluation, Plaintiff was being treated with Celexa, Trazadone*fn6 and Neurontin.*fn7 Dr. Kohn noted a diagnosis of bipolar affective disorder and inpatient treatment for depression in January 2000. (AR. at 194). She also noted that Plaintiff received outpatient treatment from Stairways between November 2001 and August 2003, during Plaintiff's incarceration. Id. Dr. Kohn noted no history of aggressive behavior, but a history of being a victim of violence and abuse, as well we extensive drug and alcohol involvement. (AR. at 195). Plaintiff reported to Dr. Kohn that she was unemployed at the time of the evaluation because her bi-polar symptoms and drug use interfered with her ability to work. Id. She noted Plaintiff's history of DUI and drug convictions. (AR. at 196).

On examination, Dr. Kohn noted that Plaintiff was cooperative with good eye contact. Id. She noted no unusual mannerisms, spontaneous speech with normal rate and volume and noted that Plaintiff was normally productive. Id. Plaintiff showed no loose associations, thought blocking or flight of ideas. Id. Plaintiff was not internally preoccupied. Id. Plaintiff reported that she had no delusions, hallucinations, suicidal, homicidal or self-destructive impulses, but did exhibit feelings of guilt. Id. Dr. Kohn indicated that Plaintiff's self-esteem was improved since her drug rehabilitation. She noted no short or long term memory impairment. Id. Dr. Kohn diagnosed Plaintiff as having bipolar affective disorder, polysubstance abuse in early remission. (AR. at 197). She assigned Plaintiff a GAF of 65-70. Id.

Plaintiff was a walk-in at Stairways in August 2004. (AR. at 198). The records indicate that she asked to see a nurse because she was "going too fast." Plaintiff stated that she was having racing thoughts, but the records indicate that the nurse did not believe Plaintiff was manic or hypo manic. Id. On September 22, 2004, Plaintiff called Stairways, indicating that her hands were shaking and "she felt manicky." Id. Plaintiff called again on September 15, 2004, indicating that she felt shaky and had rapid speech. Dr. Kohn changed her medication. Id. Plaintiff called on September 30, reporting mood swings. Id. She was kept on the same medication regimen. Id.

Plaintiff called Stairways on March 22, 2005, complaining of poor sleep and persistent depression. Id. Her medication was not changed. Plaintiff was a no-show at regular appointments in September and October of 2005. In October 2005, Plaintiff complained of an inability to sleep. The records note that Plaintiff had major surgery prior to this appointment on her C6-7 discs. (AR. at 200).

Dr. Kohn completed a medical source statement on August 29, 2006. (AR. at 202-203). Dr. Kohn opined that Plaintiff would have moderate limitations in her ability to understand, remember and carry out short, simple instructions and moderate ability to carry out detailed instructions. (AR. at 201). She also indicated that Plaintiff would have moderate limitations in her ability to make judgments on simple work-related decisions. Id. Dr. Kohn indicated that her clinical findings of obsessions and ruminations, which interfere with Plaintiff's concentration, supported her opinions.

Id. Dr. Kohn also noted that Plaintiff's ability to respond to supervision, co-workers and work pressures would be affected by her impairments. (AR. at 203). She also indicated moderate limitations in Plaintiff's abilities to interact appropriately with the public, supervisors and co-workers and to respond appropriately to work pressures in the usual work setting. Dr. Kohn opined that, in addition to these limitations, Plaintiff's reliability and customer relations would be affected by mood swings and irritability. Id. Dr. Kohn noted that her opinions would likely not change, regardless of Plaintiff's complete abstinence from drugs and/or alcohol. Id.

Dr. Paul Kohut, D.O. and Dr. Conrad Fraider, D.O.

Treatment records from Dr. Paul Kohut, D.O., indicate that Plaintiff was seen on numerous occasions for neck and back pain. (AR. at 206- 220). The records from Dr. Kohut, as early as 2000, Plaintiff was seen with complaints of pain and disc herniation at C6-7. (AR. 220). In 2000, the medical records indicate that Plaintiff had degenerative disc disease at C3 through C6. (AR. at 224).

Plaintiff was seen by Dr. Kohut numerous times in 2004. In 2000 and again in 2004 Plaintiff was treated for chronic pain with Lortab.*fn8 (AR. at 208- 215) In October 2004, Plaintiff reported increased neck and back pain. (AR. at 208). An MRI of the cervical spine showed cervical spondylosis and likely paraspinal spasm. (AR. at 221). The results also showed disc dessication with diffuse bulging at multiple levels from the C3 through C7. Id.

Plaintiff was seen by Dr. Conrad Fraider, D.O. multiple times in 2004 and 2005 in regard to her chronic back and neck pain. (AR. at 228). Records from Dr. Fraider indicate that Plaintiff was treated with injections of Kenalog and Xylocaine. (AR. at 245). She was also treated at various times with various pain medications, including Vicodin, (AR. at 245), fentanyl and Duragesic. (AR. at 235). In August 2005, Dr. Conrad opined that an anterior cervical at C6-7 would be problematic and indicated that a posterior approach at C6-7 would be the best surgical option to relieve Plaintiff's pain. (AR. at 228). The radiology records indicate that Plaintiff had multilevel cervical spondylosis, left foraminal lateral recess at C6-7 and disc herniation. (AR. at 233). Plaintiff underwent a cervical fusion at the C-7 level on September 22, 2005. (AR. at 226).

Plaintiff continued to complain of neck and back pain after the cervical fusion. (AR. at 280). She was administered a cervical epidural anesthetic and steroid on January 11, 2006, (AR. at 268), and again February 8, 2006, ...

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