United States District Court, W.D. Pennsylvania
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 Bethany Johnson ("Plaintiff' or "Claimant") for benefits under Title II ("Social Security Disability Income")("SSDI") of the Social Security Act, pursuant to 42 U.S.c. § 1382(c)(3) (2013). Plaintiff argues that the decision of the Administrative Law Judge (, "ALJ") was erroneous and contrary to law [See ECF No. 1 at 2]. As such the Plaintiff requests that benefits be awarded to Plaintiff retroactive to the date of initial disability [ECF No.1 at 3].
To the contrary, Defendant argues substantial evidence supports the Commissioner's decision. "Although Plaintiff had mental and physical impairments, she acknowledged she was working during the period of alleged disability for up to 30 hours per week in a light duty job, spent up to 40 hours per week cleaning her own home, and cared for three children [ECF No. 18 at 1]. Therefore, the ALJ's 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.
The Court has reviewed the record in its entirety and for the reasons stated below we will deny the Plaintiff's Motion for Summary Judgment and grant the Defendant's Motion for Summary Judgment.
II. Procedural History
On October 12, 2010 the Plaintiff protectively filed a Title II application for a period of disability and disability insurance benefits ("DIB"), alleging disability beginning April 13, 2010 (R. at 12). Plaintiff alleges disability due to repeated right shoulder rotator cuff tear with multiple surgical repairs, post-traumatic stress disorder ("PTSD"), bipolar disorder, mood disorder, obsessive compulsive disorder ("OCD"), attention deficit hyperactivity disorder ("ADHD"), and generalized anxiety disorder [ECF No.8 at 1]. Plaintiff's claims were denied at the initial level of the administrative review process on February 14, 2011 (R. at 12). On April 7, 2011 Plaintiff requested a hearing (R. at 12). ALJ David F. Brash conducted a de novo video hearing on April 4, 2012 (R. at 12) where Plaintiff was in Erie, Pennsylvania and the ALJ was in Mars, Pennsylvania. Present for the hearing was an impartial Vocational Expert ("VE"), William H. Reed, Ph.D. (R. at 12). On May 3, 2012, the ALJ determined that Plaintiff was not disabled under the Social Security Act (R. at 9-21). The Plaintiff filed a timely written request for review by the Appeals Council which was denied on June 11, 2012 CR. at 1-2), making the ALJ'S decision the final decision of the Acting Commissioner. An appeal was subsequently filed by Plaintiff who seeks our review of the ALJ's decision.
III. Medical History
June 15, 2005 Dr. Fuat Ulus of St. Vincent Health Center reported that Plaintiff was referred to the program when Wellbutrin, Lexapro, Xanax and Effexor were ineffective for treating Plaintiff's anxiety, depression and low frustration tolerance. Patient had anxiety and depression for three years starting during a time of postpartum. She had increased sleep and appetite with weight gain. She was irritable and less social. There was a history of a car accident with head trauma (R. at 294). The St. Vincent report stated Plaintiff has a Current Olobal Assessment of Functioning ("GAF") of 60-65 (R. at 295). Dr. Ulus ordered an EEO to rule out any neurological problems before entering the psychiatric jurisdiction (R. at 295).
August 2, 2005 Dr. Ulus of St. Vincent Health Center reported that Depakote had really started to help Plaintiff's mood stabilization and anger management. Plaintiff's OAF was 65 (R. at 292).
February 22, 2006, during a visit to St. Vincent Health Center, Plaintiff reported being frustrated, anxious, and depressed. She further reported that her medications were not helping and were all discontinued for a regimen of Topamax CR. at 291).
On August 31, 2006 Plaintiff met with Dr. Ulus at St. Vincent Health Center. She continued on Topamax and agreed to see a counselor for cognitive behavioral therapy and management of her Obsessive Compulsive Disorder ("OCD"), anxiety and other difficulties (R. at 289).
On October 24, 2008 Plaintiff underwent a psychiatric evaluation with Rose Ann R. Flick, CRNP at St. Vincent Health Center. Plaintiff was fearful that she might relapse into a manic episode due to stressors. Plaintiff's OAF was noted at 65-68 and she was reported to be well-groomed and pleasant. Plaintiff was prescribed Topamax for headaches and mood stabilization and Klonopin for anxiety and agitation. Supportive psychotherapy was suggested for herself and her family (R. at 285-288). Diagnostic impressions were: PTSD, adjustment disorder, and Bipolar I affective disorder mixed, mild to moderate (R. at 287).
On November 21, 2008 Plaintiff was seen on an outpatient basis at St. Vincent Health Center. Plaintiff reported doing better at work and said her frustration was gone. She was also sleeping better and was more productive (R. at 284).
On May 11, 2009 Plaintiff was seen on an outpatient basis at St. Vincent Health Center. Plaintiff was feeling overwhelmed and depressed because her son was in trouble with drugs. The assessment had a note of GAF of 60 (R. at 283).
On August 13, 2009 Plaintiff was seen for ADHD and Generalized Anxiety Disorder (GAD). Plaintiff reported that her current medication was not addressing her anxiety. Her dosage of anti-anxiety medication was increased (R. at 282).
On April 28, 2010 Plaintiff was seen at St. Vincent Health Center and reported having difficulty concentrating, focusing, and completing tasks. She was prescribed Adderall (R. at 281).
On April 11, 2010 Plaintiff visited Hamot Medical Center Emergency Department after a slip and fall accident. Plaintiff reported right arm pain for four days since the fall. She was unable to raise her right arm (R. at 309). She was discharged with a diagnosis of Bursitis (R. at 310). April 21, 2010 Plaintiff had initial visit with Dr. Jeffrey Nechleba regarding her right shoulder pain. X-rays were normal. The Doctor suspected rotator cuff injury and ordered an MRI (R.at 376). In the meantime Plaintiff continued in physical therapy to improve her motion (R. at 377).
On May 4, 2010 an MRI of Plaintiffs right shoulder was performed. "Impression: 1. Supraspinatus Full-Thickness tear at its insertion. 2. Small joint effusion and small amount of fluid within subacromial-subdeltoid bursa." CR. at 320).
On June 3, 2010 Plaintiff underwent surgery for a right shoulder massive rotator cuff tear. The procedure included diagnostic arthroscopy, arthroscopic bursectomy, and mini open repair of massive rotator cuff tear. The anchors were Arthrex 5.5-mm Bio corkscrews for a medial row and then 3 Bio Push-Locs out laterally. Insertion of pain pump catheter into the subcromial extra articular space (R. at 303).
On October 15, 2010 Dr. Jeffrey Nechleba saw Plaintiff for a visit after a fall about a month and a half prior. Plaintiff fell in the first two months after surgery to repair rotator cuff. The Doctor waited to see if the pain would settle after therapy but the pain persisted. Dr. Nechleba performed an MR arthrogram of her right shoulder. The MR was accomplished in the axial, oblique coronal and sagittal planes. There was considerable artifact generated by metallic component of surgical hardware, with anchors noted within humerus. There was fluid seen throughout the subacromial/subdeltoid bursa which would be evidence of a recurrent full thickness or rotator cuff tear. Visualized portions of the rotator cuff were found to be quite attenuated. There was some obscuration by artifact. There was some contrast material within the subscapularis tendon, which was possibly iatrogenic. Labrum was intact as were the biceps tendon and anchor. Findings were consistent with a recurrent full thickness rotator cuff tear (R. at 318). Dr. Nechleba scheduled another rotator cuff surgery (R. at 312).
On November 5, 2010 Plaintiff was seen for outpatient psychiatric treatment at St. Vincent Health Center where she said she was feeling "a little depressed." Plaintiff began taking antidepressant medication (R. at 280, 552).
On November 8, 2010 Plaintiff had a second rotator cuff operation for a re-tear of her rotator cuff (R. at 257). Diagnosis was right shoulder partial thickness articular-sided rotator cuff tear and biceps tear (R. at 257). At the Village Surgicenter, Dr. Jeffrey Nechleba performed diagnostic arthroscopy with bursectomy and then biceps tenodesis and then mini open rotator cuff repair. Anchors were 3 medial row 6.5 mm Arthrex Bio-corkscrews, PEEK, and then 2 swivel-licks placed laterally for a double-row repair CR. at 257).
Kathy Sullivan provided a report on behalf of Jeffrey A. Nechleba on November 19, 2010. Plaintiff had a post-op appointment after a re-tear of her rotator cuff. Appointment was normal and she was provided with a prescription to ...