United States District Court, M.D. Pennsylvania
MICHAEL A. WALLACE, Plaintiff,
CAROLYN W. COLVIN,  Acting Commissioner of Social Security, Defendant.
WILLIAM J. NEALON, District Judge.
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff Michael Wallace's claim for social security disability insurance benefits. For the reasons set forth below, the decision of the Commissioner will be affirmed.
Disability insurance benefits are paid to an individual if that individual is disabled and "insured, " that is, the individual has worked long enough and paid social security taxes. The last date that a claimant meets the requirements of being insured is commonly referred to as the "date last insured." Wallace met the insured status requirements of the Social Security Act through March 31, 2011. (Tr. 11).
Wallace was born on November 16, 1962 and was forty-two (42) years old on the alleged disability onset date. (Tr. 16, 127). Therefore, he was considered a "younger individual" whose age would not seriously affect his ability to adjust to other work. (Tr. 16); 20 C.F.R. §§ 404.1563(c), 416.963(c). Wallace graduated high school and has past relevant work as a truck driver. (Tr. 16).
Wallace protectively filed an application for disability insurance benefits on February 4, 2009, alleging disability since October 23, 2005 due to pain in his neck, back, arms and legs, diabetes and headaches. (Tr. 9, 127-28, 149). After his request for benefits was denied at the initial level, he filed a request for a hearing before an administrative law judge ("ALJ"). (Tr. 71-73). A hearing was held on July 12, 2010. (Tr. 19-62). The ALJ issued a decision on August 16, 2010 denying Wallace benefits. (Tr. 6-17). Wallace then requested review by the Appeals Council which, by Notice of Action dated April 13, 2012, denied review, making the decision of the ALJ final. (Tr. 1-5, 18).
On June 6, 2012, Wallace filed a complaint in this Court seeking review of the Commissioner's denial of his application for Social Security disability benefits. (Doc. 1). The Commissioner filed an answer to the complaint and a copy of the administrative record on August 14, 2012. (Docs. 5, 6). Wallace filed the brief in support of his appeal on September 13, 2012, and the Commissioner filed her brief on October 9, 2012. (Docs. 8, 9). The matter is ripe for disposition and, for the reasons set forth below, the Commissioner's decision will be affirmed.
Standard of Review
When considering a social security appeal, the court has plenary review of all legal issues decided by the Commissioner. See Poulos v. Commissioner of Social Security , 474 F.3d 88, 91 (3d Cir. 2007); Schaudeck v. Commissioner of Social Sec. Admin. , 181 F.3d 429, 431 (3d Cir. 1999); Krysztoforski v. Chater , 55 F.3d 857, 858 (3d Cir. 1995). However, the court's review of the Commissioner's findings of fact pursuant to 42 U.S.C. § 405(g) is to determine whether those findings are supported by "substantial evidence." Id .; Mason v. Shalala , 994 F.2d 1058, 1064 (3d Cir. 1993); Brown v. Bowen , 845 F.2d 1211, 1213 (3d Cir. 1988). Factual findings which are supported by substantial evidence must be upheld. 42 U.S.C. § 405(g); Fargnoli v. Massanari , 247 F.3d 34, 38 (3d Cir. 2001) ("Where the ALJ's findings of fact are supported by substantial evidence, we are bound by those findings, even if we would have decided the factual inquiry differently."); Cotter v. Harris , 642 F.2d 700, 704 (3d Cir. 1981) ("Findings of fact by the Secretary must be accepted as conclusive by a reviewing court if supported by substantial evidence."); Mastro v. Apfel , 270 F.3d 171, 176 (4th Cir. 2001); Keefe v. Shalala , 71 F.3d 1060, 1062 (2d Cir. 1995); Martin v. Sullivan , 894 F.2d 1520, 1529 & 1529 n.11 (11th Cir. 1990).
Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Pierce v. Underwood , 487 U.S. 552, 565 (1988) (quoting Consolidated Edison Co. v. N.L.R.B. , 305 U.S. 197, 229 (1938)); Johnson v. Commissioner of Social Security , 529 F.3d 198, 200 (3d Cir. 2008); Hartranft v. Apfel , 181 F.3d 358, 360 (3d Cir. 1999). Substantial evidence has been described as more than a mere scintilla of evidence but less than a preponderance. Brown , 845 F.2d at 1213. In an adequately developed factual record, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency's finding from being supported by substantial evidence." Consolo v. Federal Maritime Commission , 383 U.S. 607, 620 (1966).
Substantial evidence exists only "in relationship to all the other evidence in the record, " Cotter , 642 F.2d at 706, and "must take into account whatever in the record fairly detracts from its weight." Universal Camera Corp. v. N.L.R.B. , 340 U.S. 474, 488 (1971). A single piece of evidence is not substantial evidence if the Commissioner ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason , 994 F.2d at 1064. The Commissioner must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Johnson , 529 F.3d at 203; Cotter , 642 F.2d at 706-707. Therefore, a court reviewing the decision of the Commissioner must scrutinize the record as a whole. Smith v. Califano , 637 F.2d 968, 970 (3d Cir. 1981); Dobrowolsky v. Califano , 606 F.2d 403, 407 (3d Cir. 1979).
Sequential Evaluation Process
To receive disability benefits, the plaintiff must demonstrate an "inability to engage in any substantial gainful activity by reason of any 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 not less than 12 months." 42 U.S.C. § 432(d)(1)(A). Furthermore,
[a]n individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work. For purposes of the preceding sentence (with respect to any individual), "work which exists in the national economy" means work which exists in significant numbers either in the region where such individual lives or in several regions of the country.
42 U.S.C. § 423(d)(2)(A).
The Commissioner uses a five-step process in evaluating disability insurance and supplemental security income claims. See 20 C.F.R. § 404.1520 and 20 C.F.R. § 416.920; Poulos , 474 F.3d at 91-92. This process requires the Commissioner to consider, in sequence, whether a claimant (1) is engaging in substantial gainful activity, (2) has an impairment that is severe or a combination of impairments that is severe, (3) has an impairment or combination of impairments that meets or equals the requirements of a listed impairment, (4) has the residual functional capacity to return to his or her past work and (5) if not, whether he or she can perform other work in the national economy. Id . As part of step four, the administrative law judge must determine the claimant's residual functional capacity. Id . If the claimant has the residual functional capacity to do his or her past relevant work, the claimant is not disabled.
Residual functional capacity is the individual's maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis. See Social Security Ruling 96-8p, 61 Fed. Reg. 34475 (July 2, 1996). A regular and continuing basis contemplates full-time employment and is defined as eight hours a day, five days per week or other similar schedule. The residual functional capacity assessment must include a discussion of the individual's abilities. Id .; 20 C.F.R. §§ 404.1545 and 416.945; Hartranft , 181 F.3d at 359 n.1 ("Residual functional capacity' is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).").
In 2004, Wallace fell off a truck and landed on his left shoulder and neck. Initially, he did not have much pain, though he was achy and stiff at times. Around September 2004, Wallace began experiencing significant neck pain, pain radiating down his left arm, and constant numbness and tingling. Wallace went to the emergency room on September 29, 2004, with complaints of left shoulder pain. (Tr. 259-60).
Wallace began treating with Stephen K. Powers, M.D., a neurosurgeon, in 2004. (Tr. 217-35). In November 2004, Wallace presented to Dr. Powers with complaints of pain in the left side of his lower neck, upper shoulder and arm area and extending occasionally with pain over the anterior lateral thigh on the left. (Tr. 231). Dr. Powers noted that Wallace has a "left C4 primarily painful sensory radiculopathy with some minor motor component." (Tr. 232). Dr. Powers recommended surgery to open up the neural foramen and he recommended a CT scan. (Tr. 232).
In November 2004, Wallace had a CT scan of the cervical spine which revealed severe narrowing of the neural foramina on the left side at the C3-C4 level due to bony spurring and osteophyte formation within the left facet joint. (Tr. 234). On November 22, 2004, Wallace underwent cervical spine surgery for removal of a growth and decompression of the left C4 nerve root. (Tr. 13, 234).
On December 8, 2004, Wallace reported to Dr. Powers that he continued to have pain in the left side of his lower neck, left shoulder and arm area and extending occasionally with pain over the anterior lateral thigh on the left. (Tr. 229). Dr. Powers noted that a CT scan revealed an osteomatous appearing growth off the undersurface of the left C4 pars superior down into the neural foramen. (Tr. 229). Dr. Powers recommended surgery to remove the growth. (Tr. 229-30). Dr. Powers reviewed the CT scan and recommended a left C4 microforaminotomy to remove the lesion. (Tr. 230). Dr. Powers explained that if he did not have the surgery, he would have progressive motor weakness of his left cervical trapezius and continued pain. (Tr. 230).
On December 30, 2004, Wallace underwent a left C3-4 extensive foraminotomy and microsurgical removal of osteoma involving the left C3 pedicle and pars with decompression of the left C4 nerve root. (Tr. 226, 253-57).
On January 12, 2005, after the procedure, Wallace reported that he was doing well but still had some left shoulder tenderness. (Tr. 226). Dr. Powers told Wallace to increase his activity over time, to continue walking, and not to lift anything much over 15-20 pounds for the following four weeks. (Tr. 226-27). He also informed Wallace about exercises he could do to relieve the muscle spasms in his upper extremities and upper back. (Tr. 226-27). Dr. Powers recommended a follow-up visit and stated they would make a determination at that time about when Wallace should be back to driving a truck. (Tr. 227).
In February 2005, Dr. Powers noted that Wallace continued to have "quite a bit of left upper shoulder and neck discomfort", numbness over the top of the left shoulder and extending down to the deltoid region. (Tr. 224). Dr. Powers stated that Wallace had excellent shoulder strength, but he also had numbness, motor weakness, and restricted neck movement. (Tr. 224). Wallace was suffering from paraspinal muscle spasm and trapezius discomfort related to the decompression at C3-4 and his numbness was due to sensory disturbance from nerve root decompression and probably from contusion of the nerve with the decompression. (Tr. 224). Dr. Powers recommended therapy and he did not think Wallace was ready to return to work and noted that he would re-evaluate him in four weeks to make a determination at that time. (Tr. 224-25).
On March 23, 2005, Dr. Powers saw Wallace for his third postoperative visit. (Tr. 222). Wallace stated that he had been going to physical therapy for one month and it was "greatly helping his symptoms" and his pain had greatly improved. (Tr. 222). He still complained of pain in the posterior neck and numbness around the incisions, left shoulder and trapezius aching and aching in the left upper arm, and tingling and numbness in the left arm and hand. (Tr. 222). Dr. Powers stated that Wallace should continue his last two weeks of physical therapy and may return to work on April 11, 2005. (Tr. 223).
Wallace underwent an MRI of the cervical spine on October 4, 2005. Dr. Powers noted that there were no significant changes from Wallace's previous, preoperative studies from October 2004. (Tr. 220, 406). The MRI revealed mild disc degenerative changes at the C3-4 level with hypertrophic degenerative changes of the left C3-4 facet joint, contributing to left C3-4 neural foraminal narrowing; small central protrusion of the C4-5 disc; mild posterior bulge of the C6-7 disc; and no evidence of cervical spinal cord compression or edema. (Tr. 220, 406).
On October 24, 2005, Wallace told Dr. Powers that he was at work lifting heavy boxes and got a sharp stabbing pain that shot down into the back of his neck and up the back of his head. (Tr. 220). At work, Wallace lifted boxes weighing about 170 pounds, and he loaded between 13 and 14 boxes on each skid. (Tr. 221). Dr. Powers believed that this was "pushing the limits" due to Wallace's age and the weakness in his left trapezius muscle. (Tr. 221). Dr. Powers stated that Wallace is "at a point now where he is unable to carry out the type of heavy labor that he has been performing for the last 20 years" and that he should consider a job change. (Tr. 221). Dr. Powers advised that Wallace stop working until his pain subsided. (Tr. 221). He prescribed physical therapy three times a week for six weeks. (Tr. 221).
On December 7, 2005, Wallace returned to see Dr. Powers due to increased and continued pain despite finishing physical therapy. (Tr. 218). Wallace stated that he was experiencing spasms in the left shoulder and left side of the neck and into the left scapula. (Tr. 218). Dr. Powers stated that Wallace has a chronic pain problem around the left shoulder and he referred him to a pain management specialist. (Tr. 218).
Wallace treated with William A. Rolle, Jr., M.D., on January 17, 2006 for a physiatric evaluation and treatment of his cervical and left upper extremity pain. (Tr. 242-43). Dr. Rolle's impression was cervical pain with left upper extremity radicular symptoms. (Tr. 243). He ordered an MRI of Wallace's cervical spine and an EMG of the left upper extremity. (Tr. 243). Dr. Rolle prescribed Lyrica and recommended a follow-up visit. (Tr. 243).
On January 18, 2006, Wallace underwent an MRI of the cervical spine which revealed degenerative changes of the cervical spine resulting in mild canal and neural foraminal encroachment. (Tr. 244-45). There was no evidence of abnormal postoperative ...