United States District Court, W.D. Pennsylvania
MAURICE B. COHILL, 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 Leonard Leroy Vergith ("Plaintiff' or "Claimant") for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("SSA"), 42 U.S.C. §§ 401-434 and 1381-1383f(2012). Plaintiff argues that the decision of the Administrative Law Judge ("ALl") was erroneous and that the Commissioner's decision was not supported by substantial evidence as required by 42 U.S.C. § 405(g) [ECF No.9 at 3].
To the contrary, Defendant argues that the medical evidence was minimal, and because Plaintiffs impairments did not prevent him from performing a narrow range of light work as indicated by Plaintiffs Residual Functional Capacity ("RFC") [ECF No 11 at 1-2; (R at 18)], the Plaintiff is not disabled under sections 216(i) and 223(D). the Social Security Act (R. at 23). 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
The Plaintiff filed applications for SSI and DIB on September 3 and 8, 2010, respectively (R. at 14) alleging disability since December 9, 2009. Plaintiff states his disability is related to coronary artery disease status post stent placement, degenerative disc disease, right shoulder impairment, and depression (R. at 16). Plaintiff's claims were denied at the initial level of the administrative review process on October 26, 2010 (R. at 14). Plaintiff requested a hearing on de novo hearing on April 25, 2012 November 9, 2010 (R.at. 14). ALJ James Pileggi conducted a de novo hearing on April 25, 2012 (R. at 14). Present at the hearing was Vocational Expert ("VE"), Karen Krull (R. at 14). On June 1, 2012, the ALJ determined that Plaintiff was not disabled under Section 1614(a)(3)(A) of the Social Security Act (R. at 23). The ALJ stated, "After careful consideration of all the evidence, the undersigned concludes the claimant has not been under a disability within the meaning of the Social Security Act from December 9, 2009, through the date of this decision." (R. at 14).
On July 25, 2012 Plaintiff filed a timely written request for review by the Appeals Council (R. at 10), which was denied on July 10, 2013 (R. at 1-5), making the ALJ's decision the final decision of the Acting Commissioner. An appeal was subsequently filed by Plaintiff who seeks review of the ALJ's decision.
III. Medical History
On November 5, 2004 Plaintiff had an MRI of the lumbar spine. Sagittal Tl and T2 and axial T2 and proton density imaging angled to the L3-4 through L5-S1 discs was performed. Dr. Charles A. Young found disc herniation at the L3-4 and L5-S1 levels (R. at 376).
On November 23, 2009 Plaintiff attended an appointment with John C. Heflin, M.D., his primary care physician, for a follow up on chronic low back pain. Plaintiff reported good control of back pain with MS-Contin 60am/30pm. He was able to do activities of daily living and moderate duty (R. at 277). Exacerbating factors to his pain were lifting, bending, twisting, pushing and pulling (R. at 277). Plaintiff also developed right rotator cuff pain with impingement (R. at 277). His diagnoses were reported as herniated nucleus pulposus and rotator cuff syndrome (R. at 277). Plaintiff was to continue on current medications and use ice three times daily and gentle range of motion exercises with pendulum for his rotator cuff issue. Dr. Heflin discussed with Plaintiff possible physical therapy and steroid injection for his rotator cuff pain (R. at 277).
On December 9, 2009 Plaintiff presented to Meadville Medical Center with chest pain. The Medical Center took a portable chest x-ray with no significant findings (R. at 257). However, he was found to have unstable angina and acute myocardial infarction with elevated markers and no ST elevation. He was transferred to Hamot Medical Center with symptoms of crescendo angina (R. at 255). Plaintiff was admitted to Hamot Medical Center for a Non-ST-elevation myocardial infarction requiring pacemaker placement. He went directly to the cardiac catheterization laboratory where he was found to have modest disease of his left system but a severe proximal RCA stenosis. This was ballooned and stented with a single bare-metal stent with excellent angiographic results. The following day Plaintiff had persistent bradycardia with symptoms. He underwent temporary pacemaker placement with subsequent placement of a permanent dual-chamber pacemaker on December 11, 2009. On that same day an x-ray was taken of Plaintiff's chest to reveal the pacemaker was in place and working properly (R. at 245). He was discharged from the hospital on December 12, 2009 and counselled on the importance of diet, exercise and smoking cessation (R. at 220). The Hamot Medical Center notes also document his chronic back pain (R. at 224).
March 22, 2010 Plaintiff attended a follow up appointment with his primary care physician, Dr. Heflin. Plaintiff had not yet completed follow-up labs nor had he been referred to cardiac rehab. He was still smoking and not making a significant effort to quit He did not have a regular exercise program but denied any chest pain, angina, palpitations, shortness of breath, dyspnea on exertion, or edema (R. at 273). Doctor Heflin arranged a stress test and cardiac rehabilitation. He recommended to Plaintiff that he quit tobacco and requested a follow up in 2 months (R. at 273).
On March 29, 2010 Plaintiff underwent a cardiac stress test. He had a normal sinus rhythm at 77 beats per minute. There was poor R wave progression across the precordium. Plaintiff was able to complete 3 minutes and 12 seconds of exercise. He achieved 55% heart rate of the age predicted maximum. The test was terminated for fatigue and dyspnea. There were no significant ST abnormalities during exertion. Plaintiff was referred for cardiac rehabilitation (R. at 284).
On June 22, 2010 Plaintiff attended an appointment with Dr. Heflin. It was a follow up appointment for low back pain and coronary artery disease. He reported good control of stable low back pain with MS-Contin 60am/30pm and was able to do activities of daily living and light duty (R. at 269). He reported occasional sharp shooting pains to bilateral calves when bending forward and twisting (R. at 269). His pain was exacerbated by lifting, bending, twisting, pushing and pulling (R. at 265). Plaintiff completed cardiac rehab with some exercises limited by his back pain (R. at 265). Plaintiff had a diagnosis of coronary artery disease and herniated nucleus pulposus -lumbar (R. at 269). Plaintiff was told he needed to stop smoking and to continue on his current plan with a follow up in 3 months (R. at 269).
On July 1, 2010 Plaintiff underwent a cardiac stress test post myocardial infarction and status post cardiac rehab. Plaintiff was exercised according to standard Bruce protocol. Test was terminated secondary to leg discomtort and dyspnea. Plaintiff proved to have ...