The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.
Sharleen Eddy ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381 - 1383f ("Act"). This matter comes before the court on cross motions for summary judgment. (ECF Nos. 6, 9). The record has been developed at the administrative level. For the following reasons, the Commissioner‟s motion will be denied and the Plaintiff‟s motion will be granted only to the extent she seeks a remand for further consideration.
Plaintiff filed for DIB and SSI with the Social Security Administration September 20, 2007, claiming an inability to work due to disability beginning March 1, 2004. (R. at 98 -- 105)*fn1 . Plaintiff was initially denied benefits on February 1, 2008. (R. at 75 -- 84). A hearing was scheduled for May 27, 2009, and Plaintiff appeared to testify represented by counsel. (R. at 24). A vocational expert, Edith J. Edwards, also testified. (R. at 24, 94 -- 95). The Administrative Law Judge ("ALJ") issued her decision denying benefits to Plaintiff on June 16, 2009. (R. at 10 -- 23). Plaintiff filed a request for review of the ALJ‟s decision by the Appeals Council, which request was denied on May 1, 2010, thereby making the decision of the ALJ the final decision of the Commissioner. (R. at 1 -- 5).
Plaintiff filed her Complaint in this court on May 25, 2010. (ECF No. 1). Defendant filed his Answer on July 28, 2010. (ECF No. 3). Cross motions for summary judgment followed.
Judicial review of the Commissioner‟s final decisions on disability claims is provided by statute. 42 U.S.C. §§ 405(g)*fn2 and 1383(c)(3)*fn3 . Section 405(g) permits a district court to review the transcripts and records upon which a determination of the Commissioner is based, and the court will review the record as a whole. See 5 U.S.C. § 706. When reviewing a decision, the district court‟s role is limited to determining whether substantial evidence exists in the record to support an ALJ‟s findings of fact. Burns v. Barnhart, 312 F.3d 113, 118 (3d Cir. 2002).
Substantial evidence is defined as "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate" to support a conclusion. Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995)(quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). If the ALJ‟s findings of fact are supported by substantial evidence, they are conclusive. 42 U.S.C. § 405(g); Richardson, 402 U.S. at 390. When considering a case, a district court cannot conduct a de novo review of the Commissioner‟s decision nor re-weigh the evidence of record; the court can only judge the propriety of the decision in reference to the grounds invoked by the Commissioner when the decision was rendered. Palmer v. Apfel, 995 F.Supp. 549, 552 (E.D. Pa. 1998); S.E.C. v. Chenery Corp., 332 U.S. 194, 196 -- 97 (1947). In short, the court can only test the adequacy of an ALJ‟s decision based upon the rationale explicitly provided by the ALJ. The court will not affirm a determination by substituting what it considers to be a proper basis. Chenery, 332 U.S. at 196 -- 97. Further, "even where this court acting de novo might have reached a different conclusion . . . so long as the agency‟s factfinding is supported by substantial evidence, reviewing courts lack power to reverse either those findings or the reasonable regulatory interpretations that an agency manifests in the course of making such findings." Monsour Medical Center v. Heckler, 806 F.2d 1185, 90-91 (3d. Cir. 1986).
To be eligible for social security benefits under the Act, a claimant must demonstrate that he cannot engage in substantial gainful activity because of a 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 continuous period of at least 12 months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); Brewster v. Heckler, 786 F.2d 581, 583 (3d Cir. 1986). The ALJ must utilize a five-step sequential analysis when evaluating whether a claimant has met the requirements for disability. 20 C.F.R. §§ 404.1520, 416.920.
The ALJ must determine: (1) whether the claimant is currently engaged in substantial gainful activity; (2) if not, whether the claimant has a severe impairment or a combination of impairments that is severe; (3) whether the medical evidence of the claimant‟s impairment or combination of impairments meets or equals the criteria listed in 20 C.F.R., Pt. 404, Subpt. P, Appx. 1; (4) whether the claimant‟s impairments prevent him from performing his past relevant work; and (5) if the claimant is incapable of performing his past relevant work, whether he can perform any other work which exists in the national economy. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see Barnhart v. Thomas, 540 U.S. 20, 24-25 (2003). If the claimant is determined to be unable to resume previous employment, the burden shifts to the Commissioner (Step 5) to prove that, given claimant‟s mental or physical limitations, age, education, and work experience, he or she is able to perform substantial gainful activity in jobs available in the national economy. Doak v. Heckler, 790 F.2d 26, 28 (3d Cir. 1986).
Plaintiff was thirty eight years of age at the time of her administrative hearing. (R. at 27 -- 28). Plaintiff completed twelfth grade and had received some post-secondary education in cosmetology. (R. at 28, 263). Plaintiff was originally from Meadville, Pennsylvania, relocating to Florida following high school, and returning to the Meadville area in September of 2005. (R. at 33). She operated a cleaning business in Florida, which she continued in Pennsylvania. (R. at 36).
Following her return to Pennsylvania, Plaintiff was diagnosed with and treated for a number of physical and psychological conditions. Plaintiff claimed to have suffered chronic bronchitis since she was a child, and medical tests in February of 2009 confirmed that Plaintiff suffered from a history of chronic sinusitis and recurrent bronchitis with moderate airway obstruction. (R. at 429).
Plaintiff was discovered to have a baseball sized hemorrhagic cyst attached to her left ovary in 2007. (R. at 200). Plaintiff suffered moderate to extreme abdominal and hip pain that limited her functioning. (R. at 200, 230, 234, 321). No other abnormalities were found which could cause this pain. (R. at 196). Plaintiff underwent a mini open laparotomy to remove the cyst on September 10, 2007. (R. at 238, 242 -- 43). The cyst was found to be benign in nature.
(R. at 250). Following the surgery, Plaintiff was diagnosed with endometriosis, and underwent a series of treatments for this condition. (R. at 200, 242). Conservative treatment involving Lupron injections into the problem area provided no lasting relief. (R. at 238, 404 -- 11). Plaintiff was also prescribed Xanax for her anxiety while undergoing Lupron treatment. (R. at 404 -- 11). Eventually, a hysterectomy was required. (R. at 404). The procedure was completed in September of 2008 by Vladimir Nikiforouk, M.D. at the Ohio Valley General Hospital in Pittsburgh. (R. at 393 -- 96, 403 -- 04). Plaintiff‟s condition was resolved. (R. at 45).
Plaintiff was also diagnosed with degenerative disc disease. (R. at 200). Imaging studies of Plaintiff‟s back in June of 2007 established the presence of disc herniations at the L4 -- L5 and L5 -- S1 levels of Plaintiff‟s spine. (R. at 247, 256 -- 57). However, there was no evidence of central canal stenosis, and only mild right-sided neural foraminal encroachment at the L4 -- L5 level. (R. at 247, 256 -- 57). Imaging of Plaintiff‟s neck in April of 2008 showed minimal discogenic changes at the C6 -- C7 level of Plaintiff‟s spine, and was otherwise unremarkable.
(R. at 316). Plaintiff claimed to have been suffering from resultant neck, back, and leg pain since late 2006. (R. at 207, 253). The injuries to Plaintiff‟s back were allegedly attributable to the strenuous nature of Plaintiff‟s cleaning business, culminating in an incident wherein Plaintiff suffered immobilizing pain after reaching into her car before going to work one morning. (R. at 253). This pain allegedly rendered Plaintiff non-functional for seven days. (R. at 253).
Plaintiff received some treatment at Conneaut Valley Health Center for her back condition. She frequently phoned her doctor at the Health Center for stronger pain medication.
(R. at 220 -- 21, 223, 226 -- 27). She complained of neck and back pain that would not resolve.
(R. at 218, 223 -- 24). In May of 2007, she appeared at the Health Center in, "obvious," physical distress. (R. at 224). From that point on, however, Plaintiff was never noted to be in acute distress when visiting the Health Center. (R. at 218, 223 -- 24). Physical examinations of her neck in September, October, and December of 2008 all found good range of motion. (R. at 210, 213, 215).
At a July, 2007, physical evaluation with Stuart Anderson, M.D., Plaintiff‟s pain was noted as being sharp, stabbing, throbbing, aching, and burning in nature. (R. at 207). Plaintiff suffered this pain fairly constantly. (R. at 207). However, despite some paraspinal tenderness and resultant limitation in range of motion, Plaintiff walked without a limp, exhibited no tenderness in her lower extremities, had full range of motion in all joints, had negative straight leg raising test results, had no instability, and showed normal strength. (R. at 207).
At initial treatment sessions at the Meadville Medical Center‟s pain management clinic in September of 2007, Plaintiff complained of right-sided neck pain, bilateral lower arm pain, and bilateral leg pain. (R. at 253). Exercise, stairs, working, temperature extremes, bending, lifting, sitting, coughing, sneezing, light touch, walking, driving, standing, and stress all exacerbated Plaintiff‟s pain. (R. at 247). Plaintiff claimed the she had difficulty sleeping as a result of her injury, and often experienced weakness in her lower back, arms, and legs. (R. at 247). While Plaintiff consistently indicated that her pain was extreme -- eight on a pain scale of ten, she did not report the physical components of her pain in a manner consistent with the degree of pain alleged. (R. at 253). Also, she stated that with pain medication her pain was only four on a pain scale of ten. (R. at 247). It was noted that Plaintiff was recommended for pain injections at an earlier time, but had refused the procedure. (R. at 247).
Plaintiff displayed some pain behavior while at the pain management clinic, and had a slow, antalgic, but unaided, gait. (R. at 248). Plaintiff‟s spine exhibited normal cervical and lumbar lordosis, however, and had normal muscle tone and mass. (R. at 248 -- 49). She also had a full range of motion in the cervical and lumbar spine, and her sensation was intact and symmetrical. (R. at 248 -- 49). Only diffuse tenderness was noted around her spine. (R. at 248). Plaintiff was unwilling to move her lower extremities for objective testing. (R. at 248 -- 49). Lumbar epidural injections were recommended for pain relief, but Plaintiff‟s motive for seeking pain management was openly questioned in the treatment notes of the pain clinic. (R. at 249). Plaintiff frequently sought opioid pain medications. (R. at 249). The clinic noted that a drug test would need to be completed before any such pain medication was prescribed, because substance abuse was suspected. (R. at 249).
A review of Plaintiff‟s treatment at the pain clinic by Anthony Colantonio, M.D. in October of 2007 largely mirrored earlier treatment notes. (R. at 245 -- 46). He found that Plaintiff exhibited no focal neurological deficits, and her strength and effort were limited only by her reported pain. (R. at 246). Dr. Colantonio recommended epidural steroid injections for pain relief. (R. at 246). He also opined that the depression Plaintiff suffered was likely the result of her chronic pain. (R. at 246). He found it to be noteworthy that Plaintiff attempted to continue her cleaning business in spite of her pain. (R. at 246).
Lastly, Plaintiff claimed -- and it was noted -- that her physical pains had taken a significant toll on her emotional well-being. (R. at 253 -- 54). She would become tearful when describing her pain, increased irritability, anger, and depression. (R. at 254). However, Dr. Anderson ...