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McClease v. Astrue

United States District Court, Third Circuit

September 26, 2013

MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.


William H. Yohn Jr., Judge.

Plaintiff, Cathy McClease, brings this action under 42 U.S.C. § 405(g), seeking judicial review of the decision of the Commissioner of Social Security (the “Commissioner”) denying her application for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (“the Act”). I referred the matter to a magistrate judge, who submitted a report recommending that I affirm the Commissioner’s decision to deny McClease SSI benefits. McClease filed objections to the report and recommendation, to which the Commissioner responded. After independent, de novo review of the report and recommendation, and plaintiff’s objections, I will approve and adopt the report of the magistrate judge denying plaintiff’s request for review and entering judgment in favor of defendant.


A. Procedural History

McClease protectively filed an application for SSI benefits on July 31, 2006, alleging disability as of July 1, 2006, stemming from depression with psychosis, PTSD, endometriosis, scoliosis, anxiety with panic attacks, and headaches. (R. 82, 123, 127.) The Social Security Administration denied McClease’s claims for SSI benefits on October, 27, 2006. (R. 25, 82-86.) McClease then timely filed a written request for a hearing which was held before an Administrative Law Judge (“ALJ”) on March 4, 2008. (R. 34-69, 87.) McClease, represented by counsel, appeared and testified at this hearing, as did vocational expert, Daniel Rapochie. (R. 36-69).

Following this hearing, in a decision dated June 3, 2008, the ALJ denied McClease benefits. (R. 22-33.) Specifically, the ALJ found that McClease had severe impairments with regard to depression, anxiety, and a history of transient ischemic attacks, [1] and non-severe impairments with regard to hypertension and endometriosis. (R. 27, 28.) McClease’s impairments, however, did not meet the criteria of “listed impairments” in appendix 1 of the regulations provided for in the Act. (R. 28.); See 20 C.F.R. § 404, subpt. P, app. 1. Ultimately, the ALJ found that McClease has “the residual functional capacity to perform light work as defined in 20 CFR 416.967(b) except the claimant is confined to routine, one to two step tasks; the work should involve few work changes and be self paced in nature with no more than limited contact with the public or co-workers and with limited supervision.” (R. 29.)

McClease, through counsel, then filed a timely request for review of the ALJ’s decision with the Appeals Council on July 18, 2008. (R. 3, 19.) The Appeals Council granted an extension of time through January 8, 2010 for plaintiff to submit her brief in support of her request for review. (R. 12) In the interim, on October 28, 2009, I remanded a separate claim, for disability insurance benefits and supplemental security income, McClease had previously filed on October 7, 2004 (“2004 Claim”). By letter dated January 10, 2007, McClease, through counsel, rather than filing her brief, requested that the 2004 Claim be consolidated with the instant claim.[2](R. 3-4.) On May 27, 2010, the Appeals Council denied McClease’s request for review on the instant claim. (R. 9-11.) On that same date, the Appeals Council vacated the final decision in the 2004 Claim and remanded the case to the ALJ. (R. 7-8.) On June 25, 2010, McClease requested reconsideration of the Appeals Council’s denial of her request for review, referencing her January 7, 2010 letter and her request for consolidation. (R. 3-4.) On December 16, 2010, the Appeals Council denied counsel’s request. (R. 1-2.)

Thereafter, on January 25, 2011, McClease filed in this court a Request for Review of the ALJ’s decision. I assigned the matter to a magistrate judge for a report and recommendation. On July 23, 2013, the magistrate judge concluded that the ALJ’s decision was supported by substantial evidence and recommended that the court affirm the Commissioner’s decision to deny benefits. McClease filed timely objections to the magistrate judge’s report and recommendation, and the Commissioner filed a response to McClease’s objections. I will overrule the objections, approve and adopt the recommendation of the magistrate judge, and enter judgment affirming the Commissioner.

B. Factual History

McClease was born on August 31, 1959, and, at the time of the ALJ hearing in this matter, she was 48-years-old. (R. 41, 111.) McClease cares for her twelve-year-old granddaughter – the daughter of McClease’s daughter, Candace – whom she has raised since she was three-months-old. (R. 48.) Candace does not live with McClease. (R. 48, 50.) McClease also lives with a second grown daughter, and that daughter’s child. (R. 41.) McClease completed her high school education. (R. 132.) She has worked, previously, as an assembly line worker, a packer, a telemarketer, a mailsorter, and a housekeeper (R. 135, 157.) Now no longer engaged in substantial gainful activity, McClease claims that she is disabled as a result of her anxiety, depression, uterine disorder, and a history of a transient ischemic attack.

Anxiety and Depression

McClease began receiving mental health treatment at the Family Service Association of Bucks County in March 2004. (R. 244.) She meets weekly with a therapist and monthly with her psychiatrist, Randi Mittleman, M.D. (R. 242-243, 343-348.) McClease’s treatment records trace her struggle with depression and anxiety, stemming largely from her daughter, Candace’s, chaotic and violent presence in her life. (R. 284.) Candace harasses McClease and has physically assaulted McClease, McClease’s other daughter, her granddaughter, and a friend. (R. 231, 269-270, 271, 277, 284, 370.) McClease reports a constant fear of Candace coming into her home and starting “violent [and] destructive behavior.” (R. 282.) In three separate treatment plan updates, spanning nearly a year from 12/26/06 through 9/12/07, McClease’s therapist reiterates the same goal of lowering depression and increasing safety by “exploring and planning how to cope with grown children.” (R. 352-360.) To that end, the therapist worked with McClease to develop safety plans, and discussed the need for a protection from abuse order against Candace. (R. 263, 264, 271, 278, 279, 342.)

In her treatment records, Dr. Mittleman has variously noted that McClease was depressed, anxious, “very upset about circumstances, ” and “overwhelmed by life circumstances” at their sessions. (R. 337, 340, 341.) On one occasion, Dr. Mittleman noted that McClease “[r]eports spending all day yesterday in bed depressed.” (R. 336.) Dr Mittleman reports that McClease has difficulties with sleep and appetite, and had lost three pounds between November and December 2006, which was unintentional and attributable to her depression and anxiety. (R. 285, 336, 339, 341.) On December 21, 2006, in a psychiatric evaluation, Dr. Mittleman again reiterated McClease’s various life stressors, including Candace’s harassment, and noted that McClease admits to anhedonia, decreased energy and decreased concentration. (R. 285.) In addition to McClease’s therapy sessions, Dr. Mittleman has prescribed medication for McClease, including Zoloft, Wellbutrin, and Zyprexa. (R. 296.)

At her ALJ hearing, McClease reiterated the anxiety and stress she suffered because of her daughter, Candace. (R. 47-50.) She stated that her interactions with Candace leave hear “emotionally disturbed.” (R. 47-50.) She testified that her anxiety and depression have led to concentration problems that prevent her from working. (R. 46.) She reported that she can “sit here for a while, ” to do “little things, ” but then her “depression sets in” and “[she] can’t keep [her] focus.” (R. 47.) She then takes her medication and lies down, due to the pain. (R. 47.) She further reports difficulties with sleep and appetite. (R. 51, 52.)

McClease also testified to an active family life. She has raised her grandchild, Candace’s daughter, since the baby was three-months old. (R. 48.) She also watches her two-year-old granddaughter, overnight, while her other daughter is at work. (R. 50-51.) She visits with her parents at least once a week, and cared for them after her mother suffered a heart attack. (R. 56-58.) With regard to her activities outside of the family, McClease reports that she is “not a very social” person, has few friends, and visits them rarely. (R. 56.) She attends church, and was previously in the choir, but her attendance has diminished recently. (R. 60.)

Uterine Symptoms

McClease also has a history of uterine problems. From as early as 1996, Aaron Hasiuk, M.D. has treated McClease for various conditions including cysts on her ovaries, heavy menstrual bleeding, clotting and cramping. (R. 186, 196.) In May and August 2004, Dr. Hasiuk performed two surgeries, attempting to alleviate McClease’s symptoms. (R. 190-191, 197-198.) In October 2004, Dr. Hasiuk noted that it was “impossible to do the [surgeries] properly both times” and that McClease continued to experience heavy bleeding and severe cramping. (R. 202.) At that time, Dr. Hasiuk prescribed Percocet for the pain and recommended that McClease consider a hysterectomy at her three month check-up. Id.

Thereafter, according to the record, McClease sought no further medical treatment until March 20, 2007. (R. 300.) At that time, Dr. Hasiuk reported that McClease had heavy menstrual bleeding, with clotting, and severe cramps. Id. Dr. Hasiuk scheduled McClease for a pelvic ultrasound. (R. 318.) At McClease’s follow-up appointment, Dr. Hasiuk noted that McClease’s pelvic ultrasound was “completely unremarkable, ” that her endometrial stripe was normal, and that she was “not having any trouble with her periods.” (R. 298.) Due to her back pain, and “shadows in her kidneys, ” noticed during an ultrasound, Dr. Hasiuk recommended that McClease see a urologist. Id.

On July 5, 2007, Scott Hubosky, M.D., a urologist, examined McClease. (R. 322-323.) He noted her past medical history for endometriosis but made no observations of either bleeding or cramping issues during menses. Id. He did, however, recommend a CT scan of the abdomen and pelvis to check for kidney stones. Id. At the follow-up appointment on July 27, 2007, Dr. Hubosky found “no evidence of stones or obstruction in the CT scan” and “no evidence of blood on her urinalysis.” (R. 321.) Dr. Hubosky did, however, note that McClease had back pain that “seems to get worse at the time of her period.” Id. According to the record, McClease sought no further medical treatment for her uterine symptoms.

Prior to the ALJ hearing, the only other reference to these uterine symptoms consists of a single statement, on March 12, 2007, when McClease complained of “female problems” to her therapist. At the ALJ hearing, McClease testified that she continues to have “a lot of cramping, clotting, [and] heavy bleeding.” (R. 54.) She stated that her period lasts for seven days, and that “it’s so painful [she] usually stay[s] in bed on those days.” Id. McClea ...

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