United States District Court, Middle District of Pennsylvania
MICHAEL F. COOLBAUGH, Plaintiff,
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
REPORT AND RECOMMENDATION TO DENY PLAINTIFF’S APPEAL DOCS. 1, 7, 8, 13, 16
GERALD B. COHN UNITED STATES MAGISTRATE JUDGE
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff Michael F. Coolbaugh’s application for supplemental security income (“SSI”). The ALJ concluded that Plaintiff was unable to perform his past relevant work given his age, education, and residual functional capacity (“RFC”). However, the ALJ concluded, on the basis of testimony from a vocational expert (“VE”) that Plaintiff would be able to engage in other work in the national economy, such as a surveillance system monitor, order clerk, and tube operator.
The key issue in this case is whether Plaintiff’s subjective symptoms, specifically pain, would interfere with his ability to remain on task for an entire work day. If Plaintiff was unable to remain on task, the vocational expert testified that Plaintiff would be unable to engage in work in the national economy. In determining that Plaintiff’s pain would not interfere with his ability to engage in a range of sedentary work, the ALJ made an adverse credibility determination and assigned more weight to a consultative examining physician’s opinion than Plaintiff’s treating physician. The ALJ found that Plaintiff’s subjective complaints of pain were not fully credible because he was able to engage in other strenuous or time-consuming activities, because medical records from the month before his hearing indicated that Plaintiff did not report any pain and indicated that he had “no” musculoskeletal symptoms, and because Plaintiff had failed to follow his physician’s instructions to treat his pain. The ALJ found that the opinion from Dr. Clarence Mast, M.D., Plaintiff’s treating physician, was not entitled to as much weight as the opinion of the consulting, examining physician because Dr. Mast’s opinion contradicted Plaintiff’s testimony, Dr. Mast’s own treatment notes, and other medical evidence.
The Court reviews the ALJ’s decision under the deferential substantial evidence standard, where the denial of benefits must be upheld if any reasonable mind could accept the evidence as adequate to conclude Plaintiff was not disabled. Here, a reasonable mind could accept Plaintiff’s self-reported activities, medical records indicating the absence of back pain, and Plaintiff’s noncompliance with treatment to alleviate pain as adequate to find him not fully credible with regard to his subjective complaints. A reasonable mind could accept the contradictions between Dr. Mast’s report and Plaintiff’s testimony, Dr. Mast’s treatment notes, and other medical evidence as adequate to assign more weight to the consultative physician. Accordingly, the Court finds that substantial evidence supports the ALJ’s determination that Plaintiff’s subjective symptoms would not preclude him from performing a limited range of sedentary work. The Court recommends that Plaintiff’s appeal be denied.
II. Procedural Background
On March 18, 2009, Plaintiff filed an application for SSI under Title XVI of the Social Security Act. (Tr. 118-124). On October 14, 2009, the Bureau of Disability Determinationdenied this applications (Tr. 80-85), and Plaintiff filed a request for a hearing on November 27, 2009. (Tr. 88-90). On November 18, 2010, an ALJ held a hearing at which Plaintiff, who was represented by an attorney, and a vocational expert appeared and testified (Tr. 49-78). On January 3, 2011, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 11-26). On February 22, 2011, Plaintiff filed a request for review with the Appeals Council (Tr. 7-10), which the Appeals Council denied on August 13, 2012, thereby affirming the decision of the ALJ as the “final decision” of the Commissioner. (Tr. 1-6).
On September 21, 2012, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On November 20, 2012, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 7, 8). On March 4, 2013, Plaintiff filed a brief in support of his appeal (“Pl. Brief”) (Doc. 13). On May 7, 2013, Defendant filed a brief in response (“Def. Brief”) (Doc. 16). On April 30, 2014, the Court referred this case to the undersigned Magistrate Judge. On June 10, 2014, Plaintiff notified the Court that the case was fully briefed and ready for review. (Doc. 19).
III. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. 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 is a deferential standard of review. See Jones v. Barnhart, 364 F.3d 501, 503 (3d Cir. 2004). Substantial evidence “does not mean a large or considerable amount of evidence.” Pierce v. Underwood, 487 U.S. 552, 564 (1988). Substantial evidence requires only “more than a mere scintilla” of evidence, Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999), and may be less than a preponderance. Jones, 364 F.3d at 503. If a “reasonable mind might accept the relevant evidence as adequate” to support a conclusion reached by the Commissioner, then the Commissioner’s determination is supported by substantial evidence. Monsour Med. Ctr. v. Heckler, 806 F.2d 1185, 1190 (3d Cir. 1986); Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999); Johnson, 529 F.3d at 200.
IV. Sequential Evaluation Process
To receive disability or supplemental security benefits, a claimant 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). The Act requires that a claimant for disability benefits 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).
The Commissioner uses a five-step evaluation process is used to determine if a person is eligible for disability benefits. See 20 C.F.R. § 404.1520; see also Plummer, 186 F.3d at 428. If the Commissioner finds that a Plaintiff is disabled or not disabled at any point in the sequence, review does not proceed. See 20 C.F.R. § 404.1520. The Commissioner must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant’s impairment meets or equals a listed impairment; (4) whether the claimant’s impairment prevents the claimant from doing past relevant work; and (5) whether the claimant’s impairment prevents the claimant from doing any other work. See 20 C.F.R. §§ 404.1520, 416.920. Before moving on to step four in this process, the ALJ must also determine Plaintiff's residual functional capacity (RFC). 20 C.F.R. §§ 404.1520(e), 416.920(e).
The disability determination involves shifting burdens of proof. The claimant bears the burden of proof at steps one through four. If the claimant satisfies this burden, then the Commissioner must show at step five that jobs exist in the national economy that a person with the claimant’s abilities, age, education, and work experience can perform. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). The ultimate burden of proving disability within the meaning of the Act lies with the plaintiff. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. § 416.912(a).
V. Relevant Facts in the Record
Plaintiff was born on January 26, 1965, and the regulations classified him as a “younger individual” at the time of his application and on the date of the ALJ’s decision. 20 C.F.R. § 404.1563. (Tr. 65). Plaintiff has at least a high school education and past relevant work as a meat deboner and material handler. (Tr. 72, 139). Plaintiff had earnings for the years 1984 through 1997, and $2, 184.00 of earnings in 2002, but stopped working altogether in 2002 when he “could not lift anymore” and had no subsequent earnings. (Tr. 127, 136, 279). Plaintiff reported that his pain began in 1990, when he was twenty-five years old. (Tr. 154). Medical records show that Plaintiff suffered from degenerative disc disease and disc herniations in his back that remained largely unchanged from 2002 through the decision date, but refused to follow his doctor’s orders to take only the prescribed amount of medication, avoid loading or jumping out of trucks, and stop smoking, which was required for him to be able to undergo surgery to correct the problems in his back. Records submitted to the Appeals Council show that Plaintiff also refused to participate in physical therapy, wear his back brace, pursue vocational rehabilitation, or consider jobs that did not involve manual labor.
An MRI from May of 2002 indicated paracentral disc protrusion causing mild to moderate canal stenosis, a small hemangioma, and moderate degenerative disc disease. (Tr. 338-39). An MRI from January of 2003 indicated a large disc herniation, loss of disc height, and loss of signal. (Tr. 340). An MRI from May of 2004 again indicated disc herniation. (Tr. 344).
On October 31, 2008, Plaintiff was seen in the Guthrie Clinic by Aileen Colunio, FNP for a pain management consultation. Plaintiff reported that he had experienced pain from his back down into his legs since 1995, when he was working at a rock quarry. (Tr. 279, 348). Notes indicate that he stopped working in 2002. (Tr. 279). Plaintiff reported pain in his back, pain on extension, and “ambulate[d] with an antalgic gait, ambulating hunched over and having difficulty standing from the seated position or straightening out from bend over position of 45 degrees.” (Tr. 279). Plaintiff reported that his pain was a 7/10 and that pushing, pulling and twisting worsened his pain. (Tr. 279). Plaintiff had no weakness or sensory deficits. (Tr. 279). Notes indicate that Plaintiff “has seen a neurosurgeon for his pain, though they will not do surgery until the patient stops smoking cigarettes.” (Tr. 279). Ms. Colunio determined that “t]here will be no intervention of pain management to offer this patient.” (Tr. 279).
At visits with Dr. Mast on November 3, 2008 and November 11, 2008, Plaintiff’s back was tender but his neurological exams were normal. (Tr. 217-18).
On January 8, 2009, Plaintiff followed-up with Ms. Colunio, who noted that Plaintiff “[t]ook more of his pain medications than prescribed.” (Tr. 281). She noted Plaintiff was “[v]ery talkative patient [and] does not listen [so] unable to finish discussion.” (Tr. 282). Ms. Colunio urged Plaintiff to stop smoking and “[d]iscussed the importance of smoking cessation [but Plaintiff] had numerous reasons why he can’t quit.” (Tr. 283)
On January 20, 2009, X-rays of Plaintiff’s chest showed chronic changes, but no acute skeletal disease. (Tr. 232). They were suggestive of early changes of obstructive pulmonary disease, but there was no other evidence of acute disease. (Tr. 232). On the same day, he saw Dr. Mast reporting lower back pain. (Tr. 216). His back and neurological exams were within normal limits. (Tr. 216).
On February 11, 2009, Plaintiff saw Dr. Mast and complained of bilateral leg pain and being up at night. (Tr. 215). His back and neurological exams were within normal limits. (Tr. 215). On March 12, 2009, Plaintiff saw Dr. Mast to review test results. (Tr. 214). He reported back pain, but his back and neurological exams were within normal limits. (Tr. 214).
On March 18, 2009, Plaintiff filed an application for disability insurance benefits. (Tr. 118-124). Plaintiff asserted disability because he suffered from herniated disc and COPD which prevented him from lifting, twisting, or turning. (Tr. 136).
On April 10, 2009, Plaintiff saw Dr. Mast for a follow-up. (Tr. 213). His back and neurological exams were within normal limits. (Tr. 213). On May 12, 2009, Plaintiff saw Dr. Mast for a check-up and medication change. His back and neurological exams were within normal limits, and the only symptom he reported was diarrhea. (Tr. 212).
On June 7, 2009, Plaintiff presented to the emergency room at Tyler Memorial Hospital. (Tr. 193). He was triaged as non-urgent, the lowest level. (Tr. 193). He reported that, at 6:30 p.m. the previous night, his back pain came on suddenly after he was bending and twisting while loading a rug into a van at a friend’s house. (Tr. 189, 193). Plaintiff reported numbness in his feet and tenderness in his back with spasm and limited range of motion. (Tr. 193). Nursing notes indicate Plaintiff could get comfortable by changing his position. (Tr. 193). His straight leg raise, motor, sensory, and reflex exams were all normal. (Tr. 190). Plaintiff was given Toradol, Rebaxin, and Demoral and was discharged walking in stable condition. (Tr. 192, 194).
On June 12, 2009, Plaintiff had a follow-up from his emergency room visit with Dr. Mast. (Tr. 211). A review of Plaintiff’s symptoms was negative, and his back and neurological exams were within normal limits. (Tr. 211). On July 7, 2009, Plaintiff had a check-up with Dr. Mast. (Tr. 210). His back and neurological exams were within normal limits, although his back was tender. (Tr. 210).
On July 10, 2009, Plaintiff submitted a Work History Report and Function Support in support of his application for benefits. (Tr. 146-155, 171-178). He reported that he had pain in his lower back and left leg that fluctuated in severity, was exacerbated by bending, standing, walking, and temperature change, but not sitting. (Tr. 154). Plaintiff reported ...