United States District Court, W.D. Pennsylvania
NORA BARRY FISCHER, District Judge.
Judy Clawson ("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 daughter, Tina Marie Clawson's, 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. 10, 13). The record has been developed at the administrative level. 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. 13), will be GRANTED, and Plaintiff's Motion for Summary Judgment, (Docket No. 10), will be DENIED.
II. PROCEDURAL HISTORY
Ms. Clawson applied for DIB and SSI on May 14, 2010, alleging a disability onset of August 31, 2005 for purposes of receiving DIB, and April 22, 2010 for purposes of receiving SSI. (R. at 179-92, 239). Ms. Clawson claimed that she was totally disabled as a result of limitations stemming from "anxiety, " "right elbow, " "swelling of both legs and feet, " "burning of both legs and feet, " "slight herniated disk with mild nerve compression, " "cannot stay awake or do not sleep, " "thyroid, " "emotional problems, " "bipolar manic depressive disorder, " and "repeated bad teeth and related problems." (R. at 239). Ms. Clawson's claims were initially denied on December 14, 2010. (R. at 103-08, 115-20). On November 10, 2011, an administrative hearing was conducted in Johnstown, Pennsylvania, as part of a review of Ms. Clawson's claims. (R. at 39-76). Ms. Clawson was present to testify, represented by Evan W. Wolfson, and vocational expert Timothy E. Mahler was also present. (R. at 39-76). In a decision dated February 21, 2012, ALJ Marty R. Pillion found Ms. Clawson not disabled under the Act. (R. at 19-37). Ms. Clawson requested a review by the Appeals Council, but this request was denied on May 17, 2013. (R. at 1-5). 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 October 21, 2013. (Docket Nos. 10, 11). Defendant filed a Motion for Summary Judgment and brief on November 8, 2013. (Docket Nos. 13, 14). Having been fully briefed, the matter is now ripe for disposition.
III. STATEMENT OF FACTS
A. General Background Ms. Clawson was born on September 30, 1968 and was 36 years of age on her alleged disability onset date. (R. at 31). She died on March 11, 2012 as a result of acute combined drug toxicity. (R. at 17). Ms. Clawson's mother, Judy Clawson, was thereafter substituted as Plaintiff. (R. at 18). At the time of her initial application, Ms. Clawson listed her mailing address as a triplex in Latrobe, Pennsylvania. (R. at 179-85). Ms. Clawson was single and resided with her son, her son's girlfriend, her grandson, and a roommate. (R. at 44).
Ms. Clawson completed formal education through the tenth grade and later earned a GED. (R. at 44). Ms. Clawson last engaged in substantial gainful activity between 2000 and 2005 as a head cook for the Sisters of Charity. (R. at 198-99). Ms. Clawson worked in a variety of positions prior to that time, including as an assembler for Thermal Industries. (R. at 198-203). As an assembler and cook, Ms. Clawson reportedly spent most of her time on her feet. (R. at 45-46). Following her alleged disability onset date, Ms. Clawson continued to sporadically attempt to work. (R. at 196-98). Ms. Clawson subsisted on public assistance and food stamps, and received medical aid from the state. (R. at 560).
In a self-report of her functional capabilities dated June 9, 2010, Ms. Clawson indicated that she cared for two pet cats, she had no difficulties with personal care, she was capable of cooking and did so on a regular basis, she laundered her own clothes, she regularly walked several blocks to the store to pick up items that she needed, she could ride in a car, drive a car, and use public transportation, she was capable of paying bills, counting change, handling a savings account, and using checks, and she could follow written instructions. (R. at 256-65). Ms. Clawson described having issues with remembering to take medications and attend appointments without reminders, and with falling asleep. (R. at 259-60, 263). She stated that she generally kept to herself. (R. at 261). Ms. Clawson reported that her stress was "not that bad" when on her prescription medications. (R. at 262).
B. Physical Treatment History
Following a car accident in 2003, Ms. Clawson engaged in physical therapy on eleven occasions. (R. at 299). Numerous treatment methodologies had been attempted during her course of therapy. (R. at 299). Plaintiff enjoyed minimal improvement in neck and back pain due to "compliance issues with keeping her appointments." (R. at 299). Ms. Clawson voluntarily discharged herself in February 2004, because she felt that physical therapy was making her feel worse. (R. at 299). Her physical therapist indicated that "compliance issues" diminished Ms. Clawson's progress. (R. at 299).
Ms. Clawson also began to receive treatment for alleged back, neck, and arm pain stemming from her car accident at Plesko Family Chiropractic in Latrobe, Pennsylvania. (R. at 309-91). This treatment began in May 2005 and continued through April 2006. (R. at 309-91). In her last treatment note on April 21, 2006 it was indicated that Ms. Clawson still complained of pain in her back, neck, and right elbow. (R. at 391). Physical examination revealed severe spasm and significant trigger point tenderness. (R. at 391). Ms. Clawson claimed that she was not improving. (R. at 391).
On May 27, 2006, x-rays were taken of Ms. Clawson's cervical spine, wrists, and pelvis, but the results of the scans were normal. (R. at 424, 427-28). On November 3, 2008, she submitted to a right lower extremity duplex venous ultrasound, which indicated no deep vein thrombosis or other pathology. (R. at 419). Additional x-rays of Ms. Clawson were taken on December 14, 2008 and indicated no pathology in her chest; x-rays of her feet taken on August 19, 2009 were also negative. (R. at 401, 416, 417, 521).
Beginning in January 2009 Ms. Clawson engaged in pain management at Medical Frontiers, L.L.C. in North Huntington, Pennsylvania, and was most frequently under the supervision of physician assistant G. Eric Gifford, P.A.C. (R. at 622-77). Ms. Clawson's medications included Roxicodone and Methadone. ( Id. ). She typically complained of neck, lower back pain, and leg pain. ( Id. ). Edema was occasionally noted on her lower extremities, but her strength was typically full, her sensation and reflexes were intact, her straight leg-raising tests were frequently negative, and her lumbar pain was often noted to be mild. ( Id. ). Ms. Clawson was also regularly observed to be in no apparent distress, to be alert and oriented, and to be pleasant. ( Id. ). No neurological deficits were ever noted. ( Id. ). While Ms. Clawson was often maintained on significant doses of pain medication, she was advised to lose weight and exercise to help her conditions. ( Id. ). Laser therapy in addition to medication was noted to provide significant relief of Ms. Clawson's pain at "acceptable levels." ( Id. ). Ms. Clawson often corroborated that her pain was controlled with treatment. ( Id. ). Ms. Clawson's last treatment note from Medical Frontiers, L.L.C. was dated September 14, 2011, and Ms. Clawson indicated her pain was controlled. (R. at 676-77).
Notes of medical treatment at Latrobe Family Practice in Latrobe, Pennsylvania begin on February 9, 2009, and Ms. Clawson was most often treated there by primary care physician John Horne, M.D. (R. at 498-512, 521-22, 536, 540-45, 606-07, 612-20, 731, 741-48). At that time, Dr. Horne recorded Ms. Clawson's complaints of decreased energy and concentration due to depression and anxiety. (R. at 512). She had not taken psychiatric medications in several years due to financial constraints. (R. at 512). Ms. Clawson also complained of swelling in her legs. (R. at 512). Dr. Horne listed her diagnoses as hypothyroidism, depression, anemia, and hypertension. (R. at 512). Ms. Clawson was to undergo testing for treatment. (R. at 512).
In follow-up appointments with Dr. Horne, it was noted that Ms. Clawson was treated at a pain clinic, and that she was not to be prescribed pain medication. (R. at 510-11). Dr. Horne did provide psychiatric medication during periods when Ms. Clawson was not actively in therapy. (R. at 498, 501-02, 504, 506-08). Throughout his treatment history with her, Dr. Horne indicated that Ms. Clawson experienced swelling in her legs. (R. at 500, 502, 504, 612, 614-15, 617, 731). Ms. Clawson was also noted to increasingly complain of sleep disturbance. (R. at 501). Ms. Clawson's smoking and obesity were oft-noted issues. (R. at 498, 606, 612, 614, 617, 731, 743, 745). Ms. Clawson's diagnoses generally remained the same while under Dr. Horne's care. (R. at 498-512, 521-22, 536, 540-45, 606-07, 612-20, 731, 741-48). Despite her complaints of pain and mental health issues, it was noted by Dr. Horne in April 2009 and August 2009, that Ms. Clawson was capable of working. (R. at 507, 510). However, by February 18, 2010, Dr. Horne indicated in his notes that Ms. Clawson was totally disabled. (R. at 503).
An echocardiogram ordered by Dr. Horne for May 2010 revealed no significant abnormalities. (R. at 522). Sleep studies ordered by Dr. Horne on August 21 and 30, 2010, provided mixed results regarding Ms. Clawson's sleep. (R. at 540-45). The earlier study indicated that Ms. Clawson had mild sleep disordered breathing, minimal hypoxia, and moderate hypersomulence. (R. at 541). The later study indicated that Ms. Clawson had very poor sleep efficiency, abnormal sleep architecture, absence of REM or delta sleep, and daytime sleepiness. (R. at 543-45). It was recommended that Ms. Clawson lose weight, try a BiPAP machine, and practice better sleep hygiene. (R. at 544). Despite recommendations to the contrary, Ms. Clawson did not use her prescribed CPAP consistently. (R. at 612, 615, 617). Treating physicians at Latrobe Family Medicine indicated that Ms. Clawson's issues with her edema were likely secondary to her failure to properly use her CPAP, and her obesity. (R. at 614, 617).
In Ms. Clawson's final treatment note from Latrobe Family Practice on September 13, 2011, she complained of worsening low back pain. (R. at 620). However, she was observed to be in no acute distress, exhibited only "slight tenderness" over the lumbar spine, and had negative straight leg raising test results. (R. at 620).
Ms. Clawson was referred by Dr. Horne to physiatrist Bill Hennessey, M.D. for electrodiagnostic testing of her lower limbs and for evaluation/treatment recommendations regarding alleged back and leg pain beginning on November 16, 2009. (R. at 401-04). Following testing, Dr. Hennessey indicated that the study of both lower limbs was normal and there was no peripheral neuromuscular pathology. (R. at 404). He went on to opine that Ms. Clawson's complaints of foot pain were "her own subjectivity without any basis based upon her data collected to date." (R. at 401). In fact, the nature of her complaints indicating that her low back pain was worse when lying down pointed "away from a spine condition." (R. at 401). Physical examination revealed normal muscle strength, tone, and bulk, normal range of motion in the spine, no tenderness to palpation of the lumbar musculature, and negative straight leg-raising test results. (R. at 401-02). No swelling of the feet was observed. (R. at 402). Dr. Hennessey stated that Ms. Clawson was not disabled, and that "she clearly can work but has made a personal decision not to do so." (R. at 402). He recommended that she lose eighty pounds and cease smoking. (R. at 402).
An MRI of Ms. Clawson's lumbar spine ordered by Dr. Hennessey on December 8, 2009 showed that there was no abnormality other than a moderately dehydrated disc at L4-L5, with mild loss of height, mild facet joint hypertrophy, and mild foraminal narrowing. (R. at 415). Dr. Hennessey indicated that there was nothing in the electrodiagnostic tests or imaging studies of Ms. Clawson's back and feet to indicate a diagnosis consistent with Ms. Clawson's complaints. (R. at 400). Dr. Hennessey did not believe Ms. Clawson to be disabled, or in need of physical treatment. (R. at 400). Dr. Hennessey reiterated this opinion following examinations and diagnostic testing in February and March 2010. (R. at 394-95, 398-99). Dr. Hennessey's partner, Rich Kozakiewicz, M.D. refused to conduct further testing in June 2011 when Ms. Clawson failed to appear for her appointments as scheduled. (R. at 609-10).
On March 4, 2011, Ms. Clawson was first treated by podiatrist Allen A Dzambo, D.P.M. (R. at 686). Ms. Clawson complained of foot and ankle pain with accompanying numbness and swelling. (R. at 686). Upon examination, Ms. Clawson was noted to be alert, oriented, pleasant, and in no acute distress. (R. at 686). Her reflexes and sensation were all within normal limits. (R. at 686). Strength and muscle tone were normal, and there was no spasm or involuntary movement. (R. at 686). Ms. Clawson was diagnosed with ...