United States District Court, W.D. Pennsylvania
NORA BARRY FISCHER, District Judge.
Leland Frank Schaffer ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying his application for a period of disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 §§ 404-434 (the "Act"). The record has been developed at the administrative level and the parties have brought cross-motions for summary judgment. For the following reasons the Court finds that the decision of the Administrative Law Judge ("ALJ") is affirmed. Accordingly, Plaintiff's Motion for Summary Judgment (Docket No. 12) is DENIED and Defendant's Motion for Summary Judgment (Docket No. 14) is GRANTED.
II. PROCEDURAL HISTORY
On November 15, 2010, Plaintiff applied for DIB, (R. at 66, 67),  alleging physical disability starting July 31, 2010, (R. at 68). His initial claim was denied on January 5, 2011. (R. at 78-82). He then requested a hearing by an ALJ, which was granted. (R. at 90-91). On February 8, 2012, a hearing was held before ALJ Leslie Perry-Dowdell, which Plaintiff attended with counsel, Evan Wolfson, Esquire. (R. at 102-07). Plaintiff and a vocational expert, Samuel Edelman,  each testified. (R. at 121-22). On February 24, 2012, the ALJ issued an unfavorable decision, finding that Plaintiff was not disabled. (R. at 9-26). On April 23, 2012, Plaintiff filed a request to the Appeals Council to review the ALJ's decision, (R. at 7-8), and such request was denied on August 15, 2013, (R. at 1-6).
On October 7, 2013, Plaintiff, having exhausted all administrative remedies, filed a Complaint in this Court. (Docket No. 3). Defendant filed her Answer on December 31, 2013, (Docket No. 6), and later amended same on January 8, 2013, (Docket No. 9). On January 24, 2013, Plaintiff filed a Motion for Summary Judgment and Brief in Support. (Docket Nos. 12, 13). Defendant responded by filing a Motion for Summary Judgment and supporting brief. (Docket Nos. 14, 17).
A. General Background
Plaintiff was born on September 11, 1957 and was fifty-two years old on the date of his alleged disability onset. (R. at 20, 67). In his application for DIB, Plaintiff alleged disability due to atrial fibrillation,  chest pain, low back pain and seizures. (R. at 156). He earned a GED, (R. at 74), and his work history consists of positions as a gas station attendant and as a stock person at grocery stores, (R. at 157, 166). He was laid off from his last position at the gas station in July of 2010. (R. at 156). Plaintiff is married and has no children. (R. at 139). His wife does not work because she is disabled and receives Social Security benefits. (R. at 38).
In a Function Report-Adult dated December 7, 2010, Plaintiff indicated that he lived with his wife in a mobile home and engaged in activities such as watching television, feeding the dog, spending time talking with others, and doing odd jobs around the house, which includes washing clothes and getting wood for his wood-burner. (R. at 176, 179).
B. Medical History
Plaintiff was diagnosed with atrial fibrillation in February 2010 by his primary care physician, Dr. Wade Harvey. (R. at 385-86, 397). He continued to work after this diagnosis until he was laid off in July of the same year. Treatment notes indicate that Dr. Harvey monitored Plaintiff's condition at visits during February, May, and June 2010, (R. at 382, 383, 385), and he was prescribed Coumadin and Metoprolol,  (R. at 381-86). As noted by Dr. Harvey, Plaintiff continued to smoke half a pack of cigarettes per day despite his heart condition. (R. at 376-86). Dr. Harvey referred Plaintiff to James Richardson, M.D., a cardiologist, for further consultation for his cardiac condition. (R. at 379, 397). Dr. Richardson treated Plaintiff for such conditions from September 2010 until November 2011. (R. at 393-97, 466-79).
In March 2010, Plaintiff suffered a seizure due to his ingestion of a combination of alcohol and Benadryl. (R. at 384). He reported the event to Dr. Harvey in April 2011, who recommended that Plaintiff discontinue alcohol use while taking his medication. (R. at 373, 384).
On August 2, 2010, Plaintiff reported to Dr. Harvey that he experienced acute lower back pain while bending over. (R. at 381). He denied experiencing any symptoms related to radiculopathy and stated that he began using a back brace and analgesic cream to help ease the pain. ( Id. ). Dr. Harvey prescribed Naproxen and Valium to treat the pain. ( Id. ).
Two weeks later, Plaintiff visited Dr. Harvey for a follow-up examination. (R. at 380). Although Plaintiff reported feeling much better, he still complained of mild pain when twisting his back or lifting objects. (R. at 380). Despite his report of continuing discomfort, Plaintiff requested that Dr. Harvey clear him to return to work. ( Id. ). Dr. Harvey obliged and cleared him to return to work; however, he restricted Plaintiff to lifting less than five pounds for two to three weeks and requiring him to wear the back brace for at least three more weeks. ( Id. ).
On August 27, 2010, Plaintiff suffered a seizure with syncope, during which time he fell out of bed, injured his head, and bit his tongue. (R. at 211). Plaintiff was subsequently admitted to the Southwest Regional Medical Center as an inpatient from August 27, 2010 to August 30, 2010. (R. at 226). While at the hospital, it was discovered that Plaintiff had incontinence of the bladder. (R. at 226). Upon waking up, Plaintiff was confused and tired for several minutes, (R. at 228), and had no recollection of the event that put him in the hospital, (R. at 226). During his stay, Plaintiff reported to doctors that he had suffered an earlier seizure in March 2010. (R. at 226). To control the seizures, Plaintiff was prescribed Dilantin. (R. at 225, 234). Plaintiff's Dilantin levels were monitored with weekly blood tests starting on February 26, 2010 and continued to be monitored until September 27, 2010, with his dosage being changed multiple times throughout this period. (R. at 365-76). Upon discharge from the hospital, Plaintiff was advised to discontinue driving. (R. at 329).
In September 2010, Dr. Harvey noted that Plaintiff's August 2010 seizure resulted from his ceasing alcohol use. (R. at 379). It was also noted that Plaintiff's Dilantin level was low; however, he remained seizure-free. ( Id. ).
At the same time, Plaintiff began treatment and consultation with Dr. Richardson. (R. at 397). He reported occasional chest paint while working in the yard, shortness of breath with exertion, and experienced fainting and dizziness. (R. at 397). Plaintiff also advised Dr. Richardson that he was then prescribed aspirin and Metoprolol. ( Id. ) On examination, auscultation of Plaintiff's heart revealed normal heart tones and no murmurs, rubs, or gallops; however, his heart had an irregular rhythm. (R. at 398). Aside from the irregular rhythm, the examination revealed no other abnormalities. (R. at 398). The previous diagnosis of atrial fibrillation was confirmed via an electrocardiogram ("EKG"), (R. at 402), and Dr. Richardson likewise diagnosed Plaintiff with chest pain, (R. at 398). Dr. Richardson ordered a nuclear stress test to be performed in October 2010, which ultimately showed a left ventricle ejection fraction of 47 percent, no evidence of infarction or ischemia, and no arrhythmias. (R. at 289-90, 395, 398). Dr. Richardson thus recommended changes to Plaintiff's medications. (R. at 398).
Dr. Harvey reported that Plaintiff's condition remained stable and that he remained seizure-free in October 2010. (R. at 378). In follow-up examinations with Dr. Richardson around the same time period, Plaintiff complained of sporadic chest pain when carrying wood or doing other manual labor, exertion which he advised led to him becoming tired. (R. at 393, 395, 468, 470, 477). After several examinations, Dr. Richardson noted that Plaintiff's heart remained "mostly normal, " except for the continued irregular rhythm. (R. at 394, 396, 467, 468, 471). In order to achieve a regular heart rhythm, Dr. Richardson adjusted Plaintiff's medication regimen, (R. at 394, 396, 469, 471, 473, 475, 478-79), and prescribed aspirin and various anticoagulants and antiarrhythmics, ( Id. ). Dr. Richardson also advised Plaintiff to stop smoking. (R. at 394, 396, 473, 476, 478). In November 2010, Plaintiff underwent a successful cardioversion that converted him to normal sinus rhythm; however, his condition regressed to atrial fibrillation shortly after the procedure. (R. at 390, 393).
Plaintiff presented for a check-up with Dr. Richardson in December of 2010 and denied experiencing an irregular heartbeat or any fainting or dizziness. (R. at 393). Around the same time, Dr. Harvey completed a medical source statement regarding Plaintiff's ability to perform physical activities while at work. (R. at 414-15). In his statement, Dr. Harvey opined that Plaintiff could frequently lift and carry up to twenty pounds and occasionally lift and carry up to one hundred pounds. (R. at 414). To support his recommendation on Plaintiff's work limitations, Dr. Harvey suggested that Plaintiff's atrial fibrillation and seizure disorders could worsen if he was exposed to increased strain and stress while at work. ( Id. ). Dr. Harvey did not set any limitations on Plaintiff's ability to stand or walk while at work and stated that he could sit for eight hours with a sit/stand option. ( Id. ). However, Dr. Harvey did restrict him from being exposed to heights and moving machinery (on account of him being seizure-prone), as well as humidity or extreme heat because such exposure could aggravate his atrial fibrillation. (R. at 415). No further explanation was provided. ( Id. ).
In January 2011, Dr. Harvey again reported that Plaintiff's condition remained stable and that he remained seizure-free. (R. at 458). That same month, a heart examination by Dr. Richardson showed that Plaintiff's heart exhibited regular rhythm. (R. at 473). Plaintiff again denied experiencing an irregular heartbeat or any fainting or dizziness. (R. at 477).
Dr. Harvey continued to provide Plaintiff good reports on his health in April of 2011 and noted that he had not experienced a seizure "in some time." (R. at 457). Plaintiff expressed interest in being weaned off of Dilantin. ( Id. ). In response, Dr. Harvey again noted that Plaintiff's seizure ...