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Roggenkamp v. Colvin

United States District Court, Third Circuit

November 5, 2013

CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.




Becky Lynn Roggenkamp ("Plaintiff") brings this action under 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, 1381-1383(f) ("Act"). This matter comes before the Court on cross motions for summary judgment. (Docket Nos. [9], [11]). For the following reasons, the Court finds that the decision of the Administrative Law Judge ("ALJ") is supported by substantial evidence. Accordingly, Defendant's Motion for Summary Judgment, (Docket No. [11]), is GRANTED, and Plaintiff's Motion for Summary Judgment, (Docket No. [9]), is DENIED.


Plaintiff applied for DIB and SSI on December 4, 2009, alleging a disability onset of May 31, 2009 when she stopped working because of her physical and mental conditions. (R. at 161, 167).[1] She claimed that mental disabilities including bipolar disorder, attention deficit hyperactivity disorder ("ADHD"), and anxiety disorder limited her ability to work full time, and also complained of back, knee, and hip pain from multiple surgeries and two automobile accidents. (R. at 166). After both of her claims were denied on April 2, 2010, (R. at 80, 85), Plaintiff appealed her claim on May 2, 2010 and requested a hearing in front of an ALJ. (R. at 16, 194, 207). At the June 14, 2011 hearing, Plaintiff was represented by Barbara Manna, a non-attorney representative, and vocational expert Karen S. Krull testified. (R. at 33-35). In a decision dated September 21, 2011, ALJ John Kooser found although that Plaintiff had severe mental and physical impairments, she was not disabled under the Act, and thus denied Plaintiff's appeal. (R. at 16, 18). Plaintiff requested a Review of Hearing Decision before the SSA Appeals Council, (R. at 10-11), but this request was also denied. (R. at 1-4). Thus, the ALJ's decision is the final decision of the Commissioner. ( Id. ).

Plaintiff then filed a Complaint with this Court, (Docket No. [3]), followed by a Motion for Summary Judgment and Supporting Brief on July 26, 2013. (Docket Nos. [9], [10]). Three weeks later, the Commissioner timely answered with a Cross-Motion for Summary Judgment and Brief. (Docket Nos. [11], [12]). Accordingly, the matter has been fully briefed, and is ready for disposition.


A. General Background

Plaintiff was born on July 17, 1960 and was 48 years old on her alleged disability onset date. (R. at 161). At the time of her initial application, she listed her mailing address as an apartment in Ambridge, Pennsylvania. (R. at 165). However, at the ALJ hearing she testified that she was now homeless, and had been since December 2010. (R. at 41). Plaintiff said that she had been living temporarily in a dormitory at La Roche College, through a local charity, for about ten days, and would stay in this program for about one month. ( Id. ). Prior to living at La Roche, she stayed with friends. ( Id. ).

Plaintiff completed vocational training as a medical office assistant in 1985, and obtained about four years' worth of college credit as of 1992, for which she did not receive a degree. (R. at 167). Plaintiff spent 10 years working as a cashier and assistant manager for Wal-Mart, and then between September 2007 and February 2009 she worked as a clerk at a convenience store, a produce worker at a supermarket, a warehouse worker in a distribution center, and a generalized aide in setting up store displays. (R. at 42-43, 177). Plaintiff claims she stopped working in May of 2009 because of the combination of her physical and mental conditions, with the anxiety disorder symptoms being the most disabling. (R. at 44, 64, 167). She now receives public assistance. (R. at 41).

Plaintiff has never been married and has no children, although she reported she recently broke up with her life partner, with whom she used to live. (R. at 40, 209). Through her testimony and witness reports, [2] it appears that Plaintiff enjoys visiting with and sharing meals with friends, as well as playing cards or going to the movies. (R. at 59-60, 217). She is an active member and attends weekly meetings of the Society for Creative Anachronism[3] ("Society"), although she testified that she cannot participate in physical activity like she used to do. (R. at 60, 62). Depending on how much money she has, she goes to Society meetings and events as much as she can, usually about twice a week, and goes on occasional weekend trips with her friends. (R. at 62). Plaintiff has a driver's license but could not drive at the time of her hearing because of recent surgery. (R. at 41-42).

B. Medical History

At the time of her Administrative Hearing, Plaintiff claimed numerous physical and mental conditions prohibited her from working full time. (R. at 44-45, 166, 214-16). Her alleged physical disabilities consist of two herniated discs[4] and degenerative disc disease[5] of the cervical spine[6], chronic pain of her left hip due to trochanteric bursitis, [7] chronic knee pain, asthma, [8] restless leg syndrome, [9] and sleep apnea.[10] (R. at 166, 372, 438, 618). Her back, knee, and hip pain stem from a June 4, 2009 motor vehicle accident, an injury from a fall in 2007, and a subsequent spinal stenosis[11] surgery on April 11, 2011. (R. at 233-34, 250-52, 454, 466-70). She has undergone additional physical therapy for her knee pain in both knees, as she alleges that osteoarthritis[12] causes her pain as well. (R. at 47, 630-33). Plaintiff has been treated for asthma and testified she uses an inhaler to manage her symptoms. (R. at 52-53, 640, 645). Although not alleged as disabling conditions, her extensive medical record also includes evidence detailing a gallbladder removal, ovarian cysts, [13] type II diabetes, [14] hypothyroidism, [15] and hypertension.[16] (R. at 341, 343, 367-71, 384-86, 389, 435, 565, 531-45).

Regarding her mental health, Plaintiff stressed that her mental conditions are what is most debilitating. (R. at 64-65). She has been diagnosed with bipolar disorder, [17] ADHD, [18] and anxiety disorder.[19] (R. at 264-65). Plaintiff has received mental health treatment for quite some time, as she alleges she was diagnosed with bipolar disorder in 1991. (R. at 257, 311). She has been most recently treated by Dr. Apolonio Sinu, M.D. from August 2006 to November 2009, and Callie J. Cooper, LSW, from December 2009 to May 2011. (R. at 275-94, 395-403).

In her initial report to the SSA and during her testimony, Plaintiff claimed that she left work because of the stress caused by her anxiety disorder. (R. at 43, 167). Phyllis Brentzel, Psy.D., performed a mental Residual Functioning Capacity ("RFC") assessment on February 12, 2010 for the SSA. (R. at 257, 301, 309, 509). Dr. Brentzel opined that Plaintiff is limited in her "ability to understand and remember complex or detailed instructions." (R. at 311). In spite of this, she determined that Plaintiff was "able to meet the basic mental demands of competitive work on a sustained basis." ( Id. ).

This Opinion will first detail Plaintiff's physical conditions, and then turn to a discussion of her mental conditions, given the number and variety of ailments of which Plaintiff complains.

C. Physical Conditions

1. 2006 Spinal Stenosis Surgery

Plaintiff underwent spinal stenosis surgery[20] on September 29, 2006 with Dr. Derek J. Thomas, M.D. at Heritage Valley Health System in Sewickley. (R. at 218). According to the Record, [21] Plaintiff had several years of lower extremity pain and her chief complaint was "bilateral lower extremity pain, left greater than right, also with some back pain." (R. at 221, 223). Dr. Thomas reported that Plaintiff had pain in the "L5[22] distributions of both legs, left more than the right." ( Id. ). Plaintiff explained to Dr. Thomas that when "she walks at her job for any length of time, she has to sit down due to the pain until it goes away." ( Id. ). In addition, standing caused Plaintiff back pain and lower extremity pain. ( Id. ). According to the History, Plaintiff had tried multiple epidural steroid injections[23] in the past that had given her some relief, but she did not want to continue pursing that option. ( Id. ). At Plaintiff's L4-5 level[24], an x-ray and an MRI showed Grade I spondylolisthesis[25] with significant spinal stenosis, as well as significant facet arthropathy.[26] ( Id. ).

Dr. Thomas' pre- and post-operative diagnoses were spinal stenosis[27] and spondylolisthesis at the L4-L5 level. (R. at 218). Plaintiff was admitted to Heritage Valley on September 29, 2006 for surgery. ( Id. ). According to the Operative Report, he proceeded with a laminectomy[28] and fusion of L4-L5[29] using a local bone autograft[30]. ( Id. ). After placing Plaintiff under general anesthesia, Dr. Thomas and his assistant, Nancy Debranski, PA-C, "removed the posterior spinous process[31] of L4 and L5 and... cleaned that bone off, chopped it into small pieces and used that for a local bone autograft." (R. at 219). They then placed four screws into the bone, and noted that Plaintiff's "bone was of very good quality as the four screws all had excellent purchase." ( Id. ). The surgeons connected the four screws with rods, and then tested the screws, all of which were normal. ( Id. ).

After the surgery, Plaintiff spent three days recovering in inpatient care, and underwent physical therapy and occupational therapy to help her resume activities of daily living. (R. at 224). On the third day, Plaintiff "had some back soreness, [and] no leg pain." ( Id. ). A physical exam showed that her lower extremities were "intact, with 5 out of 5 strength throughout." ( Id. ). She had "slight extensor halluces longus[32] weakness on the left side compared to the right side." ( Id. ). She was prescribed pain medication and instructed to continue with physical therapy treatments upon discharge on October 2, 2006. ( Id. ).

2. 2007 Slip and Fall Accident

On February 15, 2007 Plaintiff presented to Heritage Valley Health System's emergency room because she fell down a flight of outdoor stairs while shoveling snow and ice. (R. at 233). Upon examination, Denise Ramponi, CRNP reported that Plaintiff had "mild tenderness throughout" the lumbar area[33] and a "moderate amount of soft-tissue swelling with a mild hematoma[34] on the right sacroiliac joint[35]." ( Id. ). Plaintiff demonstrated "increasing pain with any right hip movement, although most of [her] pain seem[ed] to be more posteriorly[36]." ( Id. ). Examination also showed contusions[37] at Plaintiff's lumbar area and right hip. (R. at 238). An X-ray showed no fracture or dislocation of either hip. (R. at 235). X-rays of her spine showed no acute fracture or dislocation, but did show spondylosis in Plaintiff's lower cervical spine[38] and the bilateral pedicle screws at L4-L5. (R. at 236-37). Plaintiff was prescribed twelve Vicodin[39] for her pain and was instructed to follow up with Dr. Thomas, her orthopod, in two days as "further clinical evaluation [was] indicated." (R. at 234, 236). There is no evidence of this follow-up in the Record.

3. Automobile Accident

Plaintiff was involved in a car accident on June 4, 2009, after which she began experiencing neck muscle pain on the right side and some pain down into her right arm. (R. at 251). Plaintiff was subsequently seen at Greater Pittsburgh Orthopedic Associates on June 22, 2009, at which time Dr. Derek Thomas diagnosed her with a herniated disc. ( Id. ). He ordered an MRI and prescribed Vicodin. ( Id. ). The MRI was performed on June 28, 2009, and Plaintiff followed up with Dr. Thomas on July 14, 2009 to review the results. (R. at 250). Upon review, Dr. Thomas diagnosed Plaintiff with cervical stenosis and a new herniated disc at C4-5 and C5-6. ( Id. ). Plaintiff was told the risks and benefits of possible treatment options, but she and Dr. Thomas decided to "wait and see how things go." ( Id. ). Dr. Thomas advised Plaintiff that she could return to work at her regular job and follow up in the future. ( Id. ).

4. Gallbladder Removal

Plaintiff underwent surgery to remove her gallbladder on March 1, 2010, as performed by Dr. Giselle G. Hamad, M.D., of UPMC at Magee-Womens Hospital. (R. at 341, 348). She presented to Dr. Hamad in February with abdominal pain intermittently over the past 20 years, made worse by fatty or spicy foods. (R. at 346). Dr. Hamad diagnosed Plaintiff with cholelithiasis.[40] After the exam, Plaintiff agreed to undergo a laparoscopic cholecystectomy.[41] (R. at 347). According to a letter from Dr. Hamad to Dr. Anand, Plaintiff went to the emergency room two days after surgery, complaining of abdominal pain. (R. at 341). She missed her follow-up appointment with Dr. Hamad, but three weeks later was seen again, at which point she was advised that she could return to her normal activities, and her incisions were healing. (R. at 343).

5. Type II Diabetes and Hypothyroidism

Plaintiff presented to Dr. Mona Anand, M.D., on January 12, 2011, after she obtained health insurance. (R. at 372). She complained of numerous medical conditions, including asthma, thyroid dysfunction, and hypertension, for none of which she was taking medication, and claimed she was told three years prior that she was "prediabetic." ( Id. ). She also reported symptoms from ADHD, bipolar disorder, and anxiety, for all of which she was being treated. ( Id. ). Plaintiff reported "her mental health is not the best at this time, " but she had no suicidal thoughts or intents. ( Id. ). Upon physical examination, Dr. Anand found Plaintiff's blood pressure was 132/90, and her chest was clear but "a few wheezes [were] heard." (R. at 373). Plaintiff complained of some chest pressure and shortness of breath on exertion. ( Id. ). Dr. Anand ordered numerous tests, mainly to check Plaintiff for possible coronary artery disease and for overall health maintenance. ( Id. ). She also assessed Plaintiff as suffering from hypertension with "borderline elevated pressures, " and for which she prescribed a low-salt diet. (R. at 374).

Upon follow-up to review test results, Plaintiff's blood work showed evidence of new-onset Type II Diabetes. (R. at 367). Dr. Anand reported that they "discussed the diagnosis of diabetes at length, " and she explained the lifestyle changes that Plaintiff would have to make. ( Id. ). She prescribed Glucophage[42] 1000 mg twice a day, consultation with a dietician, and a glucometer for checking her blood sugars regularly. (R. at 367-68). In addition to the Type II Diabetes diagnosis, there was also evidence of hypothyroidism.[43] For this, Dr. Anand prescribed Plaintiff with Synthroid[44] 25 mcg daily. (R. at 368). At the ALJ hearing, Plaintiff testified that "everything seems to be [in] line right now, " and that her "sugars are stable." (R. at 48).

6. Asthma

Dr. Anand reported on January 12, 2010 that Plaintiff had a history of asthma, but was not on any inhalers and was very stable. (R. at 372). Plaintiff complained of shortness of breath on exertion, and her chest examination was clear with a few wheezes heard. ( Id. ). Dr. Anand prescribed an inhaler[45] to take two puffs, as needed. (R. at 375). In March of 2010, during a Bureau of Disability Determination exam, Dr. Daniel G. Christo of Sewickley Valley Medical Group reviewed Plaintiff's symptoms and reported that she uses an inhaler to treat asthma. (R. at 329-30). Upon examination, he noted that Plaintiff's lungs were clear with no rales or wheezing, but found that Plaintiff had asthma with an unremarkable pulmonary exam, concurring with Dr. Anand's assessment. (R. at 329, 331, 333).

7. Sleep Apnea

Dr. Anand also assessed Plaintiff with sleep apnea[46] and referred her to a sleep clinic for a repeat sleep study on January 12, 2010. (R. at 374). Plaintiff complained that she had a history of sleep apnea but was currently not using a mask, although she experiences excessive snoring, and feels very tired and fatigued. (R. at 388). According to a November 2009 psychiatric progress report, Plaintiff reported getting seven to eight hours sleep; however, she later testified at the June 14, 2011 ALJ hearing that she usually sleeps about four to six hours, and uses a sleep apnea machine. (R. at 61). Dr. Christo examined Plaintiff in March of 2010, and noted that she had a history of sleep apnea, but did not bring that up as an issue at her examination. (R. at 332). In a December 2010 neuropsychological evaluation, Plaintiff reported she either "sleeps too much or not at all." (R. at 514). Dr. Glen Getz, Ph.D., a clinical neuropsychologist at Allegheny General Hospital, surmised that it was likely that a combination of her psychiatric difficulties and sleep-related problems was contributing to her subjective cognitive problems. ( Id. ). He recommended she consistently utilize her C-Pap machine[47] and possibly undergo an additional sleep study. ( Id. ).

8. Consultative Examination with Dr. Daniel Christo, D.O.

As mentioned above, on March 17, 2010 Plaintiff underwent an examination by Dr. Christo, the transcript of which was sent to the Bureau of Disability Determination. (R. at 329). Dr. Christo reported to the Bureau that Plaintiff was very vague in her medical history and told him, "my body doesn't work anymore." ( Id. ). Dr. Christo claimed that Plaintiff seemed "alert, oriented with no overt signs of thought disorder, mania, or depression." (R. at 331). Plaintiff stated to Dr. Christo that she has a poor attention span, and often has problems following and remembering instructions. (R. at 329). Plaintiff could add simple and complex numbers without any difficulty, and followed directions well. (R. at 331). Dr. Christo assessed Plaintiff's mental ...

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