YVONNE M. SHANNON, Plaintiff,
CAROLYN W. COLVIN,  Acting Commissioner of Social Security, Defendant.
MAURICE B. COHILL, Jr., Senior District Judge.
Pending before this Court is an appeal from the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying the claims of Yvonne M. Shannon ("Plaintiff' or "Claimant"), 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 argues that the decision of the administrative law judge ("ALJ") should be reversed and the Commissioner directed to award her benefits because the ALJ's determination is not supported by substantial evidence, and thus, she is entitled to benefits. To the contrary, Defendant argues that the decision of the ALJ is supported by substantial evidence, and therefore, the decision should be affirmed. The parties have filed cross motions for summary judgment pursuant to Rule 56(c) of the Federal Rules of Civil Procedure.
For the reasons stated below, the Court will deny the Plaintiffs Motion for Summary Judgment (ECF No. 10) and grant the Defendant's Motion for Summary Judgment (ECF No. 12), and affirm the decision of the ALJ.
II. Procedural History
Plaintiff filed her applications on November 17, 2009, claiming disability since August 31, 2005 due to depression, emphysema, nerve damage, bronchitis, bipolar disorder, migraine headaches, and a back problem. (R. at 145-154, 178). Her applications were denied (R. at 70-79), and she requested a hearing before an ALJ (R. at 80-81). A hearing was held on June 13, 2011, wherein Plaintiff appeared and testified, and Mary Beth Kopar, an impartial vocational expert, also appeared and testified. (R. at 31-50). On July 22, 2013, the ALJ issued a written decision finding that, absent substance abuse, Plaintiff was not disabled under the Act. (R. at 12-26). Plaintiff's request for review by the Appeals Council was denied (R. at 1-6), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). She filed her complaint challenging the ALJ's decision, and the parties subsequently filed cross-motions for summary judgment. Accordingly, the matter has been fully briefed and is ripe for disposition.
A. Medical evidence
Plaintiff began treating with Eileen Boyle, M.D., on March 11, 2008. (R. at 369). She reported a history of drug abuse, but claimed she had been "clean" for three weeks. (R. at 369). Plaintiff also reported a history of chronic pain since a motor vehicle accident in 2002. (R. at 369). She requested a prescription for Motrin and Flexeril. (R. at 369). Plaintiff indicated that she previously took Zoloft for depression and wanted to restart this medication. (R. at 369). Dr. Boyle prescribed Flexeril, Zoloft and Vistaril, and referred Plaintiff to a drug and alcohol worker for support in her recovery efforts. (R. at 369).
Plaintiff returned to Dr. Boyle on June 9, 2008 for a comprehensive medical examination. (R. at 358-359). Dr. Boyle reported that Plaintiff was fully oriented, with a normal mood and affect. (R. at 358). Physical examination revealed that her neck was supple, her lungs were clear, her extremities had no cyanosis or swelling, her peripheral pulses were intact, and she was neurologically intact. (R. at 358-359). Plaintiff was assessed with depression and cocaine abuse. (R. at 359). Dr. Boyle reported that Plaintiff declined treatment and expressed no desire to stop using cocaine. (R. at 359). Dr. Boyle counseled the Plaintiff with respect to nutrition, exercise, substance abuse, sexuality, injury prevention, and dental health. (R. 359). Plaintiff was to return "as needed." (R. at 359).
On August 13, 2008 Plaintiff requested a refill of Flexeril for lower back muscle spasms. (R. at 354). When treated for sinusitis on November 10, 2008, Dr. Boyle reported that Plaintiff was fully oriented with a normal mood and affect. (R. at 350). Plaintiff reported that she felt better because she no longer lived with her daughter, as that situation had been "very stressful." (R. at 351). On December 12, 2008, Plaintiff complained of sinus pressure and a sore throat. (R. at 340). On examination, Dr. Boyle reported that Plaintiff was well appearing, in no distress, and fully oriented with a normal mood and affect. (R. at 340). She was diagnosed with a viral upper respiratory infection. (R. at 341).
Plaintiff's prescriptions were refilled pursuant to her telephone requests in January and February 2009. (R. at 331-337). On February 11, 2009, Plaintiff complained of diarrhea and stomach cramping. (R. at 329). On physical examination, Dr. Boyle reported that Plaintiff was well nourished, in no acute distress, and fully oriented. (R. at 329). Her bowl sounds were hyperactive, but no masses or tenderness were found. (R. at 329). Plaintiff was assessed with viral gastroenteritis. (R. at 330). When seen by Dr. Boyle on March 30, 2009, Plaintiff complained of headaches at night. (R. at 322). Plaintiff denied recent drug use, but then admitted using cocaine three days prior and suffering from chest pains while using. (R. at 322). Plaintiff reported that she was not undergoing counseling or treatment for drug and alcohol abuse. (R. at 322). She reported that Zoloft helped her depression. (R. at 322).
On examination, Dr. Boyle found Plaintiff was in no distress and was fully oriented, with a normal mood and affect. (R. at 322). Dr. Boyle recommended that Plaintiff meet with a social worker in order to determine the best place to obtain care in order to address her underlying issues of past abuse, observing that Plaintiff "freely admit [ted] that she use[ d] cocaine to medicate the pain." (R. at 323). Dr. Boyle also counseled Plaintiff on the "importance of getting treatment for drug abuse" since she was at "risk for MI related to cocaine use." (R. at 323).
Plaintiff was voluntarily admitted to Forbes Regional Hospital for depression and alcohol and cocaine abuse from April 7, 2009 through April 14, 2009. (R. at 261-271). Plaintiff reported that she had "lots of manic depression and thoughts of suicide." (R. at 261). She complained of a depressed mood, poor concentration, low energy, hopelessness, and pervasive suicidal ideations. (R. at 261). Plaintiff further complained of auditory hallucinations, nightmares, and crying spells. (R. at 261). Plaintiff described some post-traumatic stress disorder symptoms following a sexual assault three to four years prior. (R. at 265). She reported a long history of issues with alcohol and crack cocaine use, acknowledging that she was "probably" an alcoholic and used crack cocaine about three days per week. (R. at 265). Plaintiff reported that she had smoked crack cocaine "about ten times" in the prior week. (R. at 261).
On mental status examination, Plaintiffs speech had decreased volume and spontaneity, her mood was depressed, and her affect was decreased in range. (R. at 266). She was alert and oriented, and there was no evidence of delusional thinking. (R. at 266). Plaintiff denied having hallucinations or suicidal thoughts, but described passive thoughts of death. (R. at 266). She was diagnosed with major depression, probably recurrent, severe; alcohol abuse, episodic; cocaine abuse; probable generalized anxiety disorder; and possible post-traumatic stress disorder, residual symptoms. (R. at 266). She was assigned a Global Assessment of Functioning ("GAF") score of 35. (R. at 266). Plaintiff was started on Zoloft, and she was encouraged to abstain from alcohol and cocaine usage. (R. at 266). She was also strongly encouraged to participate in a 12-step program. (R. at 266). In addition to alcohol/substance abuse and depression, she was diagnosed with mild asthma and allergic rhinitis per history. (R. at 268). During her stay, Plaintiff participated in therapy, and was treated with a combination of Zoloft, Seroquel and Depakote, which she tolerated well. (R. at 269). Plaintiff was medically stable during her stay, and she was assigned a OAF score of "around 45" on discharge. (R. at 269).
On May 19, 2009, Plaintiff reported that she had not seen a mental health provider since her hospitalization. (R. at 314). On June 18, 2009, Dr. Boyle completed a form entitled "Physical Capacity Evaluation", and opined that Plaintiff could stand/walk/sit for eight hours; frequently lift 11-20 pounds; use her hands and feet for repetitive movements; frequently bend; and occasionally squat, crawl and climb. (R. at 397-398). She stated that Plaintiffs diagnoses were depression/PTSD, and drug abuse. (R. at 398). She indicated that Plaintiffs onset of total disability date was March 11, 2008, her "first visit with pt." (R. at 398). Dr. Boyle opined that Plaintiff was totally disabled on a "psychiatric basis", and that she would miss more than 15 days of work a month. (R. at 398). Dr. Boyle noted that Plaintiff suffered from depression, post-traumatic stress disorder, and used cocaine to medicate for pain. (R. at 399). She further noted that Plaintiff had recently been admitted to Forbes Regional Psychiatric Unit for detoxification and questionable bipolar disorder. (R. at 399).
On June 22, 2009, Plaintiff was informed by Dr. Boyle's office that she needed to be "connected" with a psychiatrist for ongoing refills of her medication, and information regarding mental health providers was mailed to her. (R. at 312). Plaintiff failed to show for her July 13, 2009 and August 3, 2009 appointments with Dr. Boyle. (R. at 309-310). When seen by Dr. Boyle on August 7, 2009, Plaintiff complained of sinus problems. (R. at 307). She also requested a refill of her psychiatric medications. (R. at 307). On physical examination, Dr. Boyle reported that Plaintiff was well appearing, well nourished, in no acute distress, fully oriented, and had a normal mood and affect. (R. at 307). She was diagnosed with acute sinusitis and prescribed medication, and her psychiatric medications were renewed until she could be seen for her psychiatric appointment. (R. at 308).
Plaintiff failed to appear for her September 17, 2009 and September 24, 2009 appointments with Dr. Boyle. (R. at 302, 305). On September 28, 2009, Dr. Boyle performed a comprehensive medical examination. (R. at 299). Dr. Boyle reported that Plaintiff was well appearing, in no distress, was fully oriented, and had a normal mood and affect. (R. at 300). Her physical examination was normal. (R. at 300). Dr. Boyle assessed Plaintiff with bipolar disorder, and noted that she still had not established psychiatric care. (R. at 300). Plaintiff was counseled on the importance of the cessation of substance abuse. (R. at 300).
On November 13, 2009, Plaintiff complained of chills, a fever, and a sore throat. (R. at 290). Plaintiff reported that she was to begin going to Mercy Behavioral Health the following week for intake, and would be participating in group and individual therapy. (R. at 290). Dr. Boyle reported that Plaintiff was tired appearing, but in no distress. (R. at 290). Plaintiff was also fully oriented with a normal mood and affect. (R. at 290). Plaintiff was diagnosed with acute sinusitis, depression, and questionable bipolar disorder. (R. at 291).
In a "Report of Contact" dated January 28, 2010, Dr. Boyle clarified that Plaintiff had no diagnosis of COPD or emphysema, and that she had been prescribed Albuterol for allergies. (R. at 427). Dr. Boyle stated that when she saw Plaintiff on November 13, 2009, she did not notice any limitations in Plaintiff range of motion, her gait and station ...