United States District Court, M.D. Pennsylvania
REPORT AND RECOMMENDATION TO DENY PLAINTIFF'S APPEAL
Docs. 7, 8, 9, 10
GERALD B. COHN, Magistrate Judge.
REPORT AND RECOMMENDATION
I. Procedural History
On March 11, 2009, Iris Jeannette Rodriguez Torres ("Plaintiff") protectively filed a Title XVI application for Supplemental Security Income ("SSI"), alleging disability since March 11, 2009. (Tr. 20, 197).
This application was denied, and on August 6, 2010, a hearing was held before an Administrative Law Judge ("ALJ"), where Plaintiff was represented by counsel. (Tr. 20). Plaintiff and a vocational expert testified. On November 12, 2010, the ALJ issued a decision finding that Plaintiff was not entitled to SSI because Plaintiff could perform unskilled, sedentary work that was available in significant numbers (Tr. 20-30). (Tr. 19-21). On March 23, 2012, the Appeals Council denied Plaintiff's request for review, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-3).
On May 29, 2012, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 1383(c)(3), to appeal the decision of the Commissioner of the Social Security Administration denying social security benefits. Doc. 1.
On September 13, 2012, Commissioner filed an answer and administrative transcript of proceedings. Docs. 6, 7. In October and November 2012, the parties filed briefs in support. Docs. 8, 9, 10. On May 2, 2014, the Court referred this case to the undersigned Magistrate Judge. On May 27, 2014, Plaintiff notified the Court that the matter is ready for review. Doc. 12.
II. Standard of Review
When reviewing the denial of disability benefits, we must determine whether the denial is supported by substantial evidence. Brown v. Bowen , 845 F.2d 1211, 1213 (3d Cir. 1988); Johnson v. Commissioner of Social Sec. , 529 F.3d 198, 200 (3d Cir. 2008). 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, 564 (1988); Hartranft v. Apfel , 181 F.3d 358, 360. (3d Cir. 1999); Johnson , 529 F.3d at 200.
This is a deferential standard of review. See Jones v. Barnhart , 364 F.3d 501, 503 (3d Cir. 2004). Substantial evidence is satisfied without a large quantity of evidence; it requires only "more than a mere scintilla" of evidence. Plummer v. Apfel , 186 F.3d 422, 427 (3d Cir. 1999). It may be less than a preponderance. Jones , 364 F.3d at 503. Thus, if a reasonable mind might accept the relevant evidence as adequate to support the conclusion reached by the Acting Commissioner, then the Acting Commissioner's determination is supported by substantial evidence and stands. Monsour Med. Ctr. v. Heckler , 806 F.2d 1185, 1190 (3d Cir. 1986).
To receive disability or supplemental security benefits, 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. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A).
Moreover, the Act requires further that a claimant for disability benefits must show that he has a physical or mental impairment of such a 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." 42 U.S.C. § 423(d)(2)(A); 42 U.S.C. § 1382c(a)(3)(B).
III. Relevant Facts in the Record
Plaintiff was born on July 13, 1975 and was 35 years old when the ALJ issued the decision. (Tr. 14, 197). She completed 12th grade in Puerto Rico. (Tr. 41). She worked as a packer/scanner in a warehouse and at a McDonald's in Puerto Rico. (Tr. 302).
Plaintiff alleged that the conditions that limited her ability to work were her migraines, herniated discs, depression, anxiety, asthma, stomach hernia, and hiatal hernia. She stated that became unable to work because of these condition on March 11, 2009 (Tr. 242).
Plaintiff previously claimed that she could not work because she was disabled. When the agency denied her benefits in 2006, Plaintiff returned to work. Plaintiff stopped working again in 2008 because she allegedly got dizzy and fell while packaging bottles at her job. She now alleges she is disabled and has been since March 11, 2009, due to back pain and depression.
Plaintiff's request for review challenges only the ALJ's findings with respect to her alleged back pain and mental impairments (Pl.'s Br. at 6-10). The statement of facts focuses on the disputed impairments only.
B. Relevant Medical Records
1. Plaintiff's Allegations of Back Pain
On January 16, 2008, Plaintiff went to the hospital because of wheezing. The medical provider conducted a full physical examination, which revealed that the sensation in Plaintiff's extremities were intact, the deep tendon reflexes were symmetric, and Plaintiff had free range of motion of all of her joints without pain or crepitation. She had no muscle tenderness, no loss of muscle tone or strength, and no inflammation (Tr. 359). Two days later, on January 18, 2008, Plaintiff went to the hospital because of alleged shortness of breath and tenderness in her legs and upper back. The physical examination revealed that she had a normal gait, as well as full range of motion and function of her musculoskeletal system (Tr. 357). On February 19, 2008, Plaintiff reported to CRHSystem because she was experiencing back pain (Tr. 464).
By February 16, 2009, at an appointment for Plaintiff's gastrointestinal issues, she denied joint pain, restricted range of motion, weakness, muscle atrophy, or backache (Tr. 309-10). Plaintiff continued to report to the hospital for various concerns, but on each occasion, the physical examination showed good range of motion of her extremities, no back pain, and no gross musculoskeletal abnormalities (Tr. 345, 347, 349, 351, 355).
On November 5, 2009, Plaintiff went to see Sheku M. Idriss, D.O., to get a physical examination for a "medical assistance form." The examination showed that Plaintiff had full range of motion with no edema in her extremities. The neurological examination showed that Plaintiff had no sensory or motor deficits. Dr. Idriss concluded that Plaintiff was employable (Tr. 447). Among Dr. Idriss's records is a prescription for a cane (Tr. 465).
On August 13, 2010, Plaintiff had a lumbar MRI. The MRI showed "[n]o significant spinal canal stenosis and neural foraminal narrowing. Mild degenerative changes present at the lower lumbar levels with some facet degenerative changes are seen at L3-L4, L4-L5 and L5-S1" (Tr. 466).
In 2010, Plaintiff went to Blake Chiropractic and Rehabilitation (Tr. 470-90). On July 9, 2010, Plaintiff indicated that her low back pain was an eight on a ten-point scale (Tr. 482). She alleged that she had at least extreme difficulties performing all activities (Tr. 488).
On October 17, 2010, Plaintiff went to Pinnacle Health System because of an ovary issue. The physical examination showed no lower extremity numbness, weakness, or paresthesias, and no spinal tenderness. The medical provider concluded that Plaintiff "seems to have pain with movement, but she is able to get up and walk without difficulty" (Tr. 501).
On December 22, 2011, Plaintiff went to the Pinnacle Health emergency room, complaining about back pain that radiated to her legs and made it difficult to walk. Although Plaintiff reported severe, constant pain, Richard F. Luley, M.D., observed that Plaintiff was in "no apparent distress, she laughs and smiles when I leave the room, she is laughing and joking." Dr. Luley found that Plaintiff "reacts rather dramatically to light palpation throughout her back, chest, and abdomen but has no focal tenderness and no consistent tenderness." Further, Dr. Luley stated that Plaintiff's effort was poor; although she walked slowly, there was no evidence of weakness. Dr. Luley advised Plaintiff that he could "find no evidence of any acute medical problem that [he] can treat." Dr. Luley discharged Plaintiff in stable condition (Tr. 494-98).
On May 26, 2011, Plaintiff had another lumbar MRI. The MRI showed a "[n]ear normal lumbar spine MRI except for mild bilateral facet joint hypertrophy in the lower lumbar region. Right anterolateral disc bulge at L1-L2" (Tr. 499).
2. Plaintiff's Allegations of Mental Impairments
On March 13, 2008, Plaintiff reported to CRHSystem that she was experiencing depression, anxiety, and insomnia. She denied relief from Zoloft so the medical provider changed her medications (Tr. 231).
On February 16, 2009, Plaintiff went to the doctor for gastrointestinal issues She denied coping issues, mood swings, and sleep disturbances. The psychiatric examination showed that Plaintiff had appropriate judgment, full orientation, normal memory, and appropriate mood and affect (Tr. 309-10).
On April 26, 2011, Dr. Christina Vaglica, D.O., conducted a psychiatric evaluation. Plaintiff reported that she felt depressed since 2000 and "panic attacks" for three years. Dr Vaglica's examination revealed that Plaintiff's mood was anxious and depressed, but her speech was normal, thought process was linear, and her insight, judgment, and impulse control were fair. Plaintiff had no hallucinations, paranoia, delusions, or suicidal/homicidal ideations. Dr. Vaglica changed Plaintiff's medications to Cymbalta and Seroquel (Tr. 516-17).
In 2011, Plaintiff began going to NHS of Pennsylvania for her medication. The medication management progress notes reflected that Plaintiff had a depressed and angry mood, but consistently had a broad affect, cooperative behavior, and organized speech. She had no hallucinations, paranoia, delusions, or suicidal/homicidal ...