United States District Court, M.D. Pennsylvania
MEMORANDUM TO DENY PLAINTIFF'S APPEAL Docs. 8, 11, 12, 15
GERALD B. COHN, Magistrate Judge.
I. Procedural History
On November 23, 2009, Heather Heckman ("Plaintiff") protectively filed an application for Title II Social Security Disability benefits ("DIB"), with an onset date of May 7, 2009. (Tr. 120).
This application was denied, and on April 1, 2011, a hearing was held before an Administrative Law Judge ("ALJ"), where Plaintiff appeared with counsel and testified, as did a vocational expert (Tr. 30-81). On April 12, 2011, the ALJ issued a decision finding that Plaintiff was not entitled to DIB because Plaintiff could perform a range of unskilled, sedentary work that allowed for a sit/stand option (Tr. 19). On August 29, 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. 2).
On November 2, 2012, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g), to appeal a decision of the Commissioner of the Social Security Administration denying social security benefits. Doc. 1. On December 20, 2012, Commissioner filed an answer and administrative transcript of proceedings. Docs. 7, 8. In February and March 2013, the parties filed briefs in support. Docs. 11, 12. On April 29, 2014, the Court referred this case to the undersigned Magistrate Judge. On May 13, 2014, the Court issued an order providing Plaintiff the opportunity to file a reply brief and notifying the parties of the option to consent to Magistrate Judge jurisdiction. Doc. 13. On May 22, 2014, the parties consented to Magistrate Judge jurisdiction, and Plaintiff filed a reply brief in accordance with the Court's order. Docs. 14, 15.
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 is a forty year old female who was thirty-six years old at the time of her application, which is classified as a younger individual (20 C.F.R. § 404.1563) (Tr. 189). Plaintiff has a high school education (Tr. 24) and past relevant work at the substantial gainful activity level of a Cashier Checker and a Medical Records Technician (Tr. 65), and at the non-substantial gainful activity level as a Receptionist, Secretary and Unit Clerk (Tr. 66).
The Plaintiff testified to having pain in her tailbone, back, hips and knee (Tr. 54). The Plaintiff had an MRI (Tr. 99) of her right knee September 24, 2010 which showed a small effusion as well as being tender to palpitation by Dr. Oplinger, an orthopedic surgeon (Tr. 89). On May 7, 2009, the alleged onset day, the Plaintiff was at Chambersburg Hospital because her right knee had popped (Tr. 376). In June of 2009 she stated at Chambersburg Hospital that she had tripped over her dog and was diagnosed with an acute right knee sprain (Tr. 374). She was treated at the Sadler Clinic in January of 2010, even though she had no insurance, for morbid obesity, gastrointestinal reflux disease, chronic arthralgia, swelling and stiffness as well as the mental issues stated above (Tr. 431). Plaintiff again went to Chambersburg Hospital on June 13, 2010 with acute leg swelling, acute peripheral edema, hypomagnesemia, and anemia (Tr. 473). The Sadler Clinic saw Plaintiff on February 24, 2010, and noted she had multiple somatic problems as well as being grossly overweight and possibly having fibromyalgia. A consulting physical exam done by Dr. Wampler (Tr. 434) on February 18, 2010 resulted in a diagnosis of obesity, musculoskeletal problems, and rheumatoid arthritis with a marked decrease in range of motion of her shoulders (Tr. 438). He felt Plaintiff could lift 10 pounds, sit 1-2 hours in an 8 hour workday, with no limit on sitting but would need to change position as needed and could never bend, kneel, stoop, balance, crouch, or climb. He opined her reaching was affected and she should avoid poor ventilation, heights, moving machinery, vibrations, dust, fumes, odors, gases and humidity.
In the decision, the ALJ accepted that Plaintiff had the severe impairments of obesity, arthritis, bipolar disorder, asthma, hypertension, depression, anxiety, gastroesophageal reflux disease, sleep apnea, and status post carpal tunnel release (Tr. 15).
B. Relevant Medical Evidence
1. Medical Evidence Related to Plaintiff's Physical Impairments
Plaintiff alleged that she was fired from her job on May 7, 2009 - her alleged onset of disability - because she had to go to the hospital (Tr. 189, 204, 449-50). Records from the Chambersburg emergency department that day reflect that while Plaintiff complained of right knee pain, she appeared "quite comfortable" (Tr. 376). She had no knee deformity, no effusion, intact pulses and sensation, and could bend and flex her knee (Tr. 376). Her knee was stable and x-rays were unremarkable (Tr. 376, 385).
Plaintiff did not seek further treatment for five months. On October 7, 2009, she presented to the Carlisle Regional Medical Center with a "mild" right knee injury (Tr. 319). She had no other complaints (Tr. 319). Plaintiff could ambulate independently, and could "perform all activities of daily living without assistance" (Tr. 321). She had no appreciable swelling of the right knee, and was able to fully extend her leg despite reports of pain (Tr. 320). Plaintiff was discharged the same day, and rated her pain as only a two out of ten, consistent with only mild discomfort (Tr. 322).
Plaintiff presented to the Chambersburg emergency room on December 1, 2009 with complaints of "general joint aching" (Tr. 373). She denied any weakness or numbness, and had no joint swelling or redness on examination (Tr. 373). Ryan Shelley, D.O., the attending physician, noted that Plaintiff "may have fibromyalgia or rheumatoid arthritis[, ]" but did not perform any workup for these possible impairments (Tr. 373) (emphasis added). Dr. Shelley referred Plaintiff to her family physician and advised her to take ibuprofen (Tr. 373). The record does not contain evidence of a workup for arthritis, and no evidence of the requisite 11 tender points for fibromyalgia. At a January 23, 2010 emergency room visit for dizziness, Plaintiff had normal range of motion in her joints, and no swelling, deformities, or edema (Tr. 533).
On February 18, 2010, consultative examiner David Wampler, M.D., evaluated Plaintiff in connection with her application for benefits (Tr. 434). In addition to her general reports of pain, Plaintiff related new complaints not reflected in other medical records, including an inability to do anything above shoulder level "for the last two years" and problems with her "hands curling up" (Tr. 434-35). On examination, Plaintiff had normal muscle bulk, tone, and strength, but decreased range of motion in her shoulders (Tr. 438). Despite his relatively benign examination, Dr. Wampler checked boxes to indicate that Plaintiff could never perform postural movements (Tr. 439). He also indicated that Plaintiff was generally limited in her ability to reach, but did not provide specific functional abilities (Tr. 440).
Plaintiff initiated treatment at Sadler Health on January 26, 2010 (Tr. 431-32). Treatment consisted of medication management, and progress notes do not document any functional limitations (Tr. 498-523). Although Plaintiff reported pain, she did not relate any pain in her shoulders (Tr. 513). The majority of Plaintiff's treatment in 2010 related to right knee pain. Progress notes from Appalachian Orthopedic Center reflect that Plaintiff reported difficulties only with walking, squatting, and kneeling (Tr. 104). Despite her complaints, diagnostics tests of her knee were "unremarkable" and reflected only "mild" effusion (Tr. 99, 115, 490, 527). She had full range of motion in her hips (Tr. 89, 110). "Based on the lack of significant findings" in diagnostic tests, orthopedic physician Michael Oplinger, M.D., advised Plaintiff that she was not a surgical candidate (Tr. 89, 492).
IV. Review of ALJ Decision
A five-step evaluation process is used to determine if a person is eligible for disability benefits. See 20 C.F.R. §§ 404.1520, 416.920; 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 any further. See 20 C.F.R. §§ 404.1520, 416.920.
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 initial burden rests with the claimant to demonstrate that she is unable to engage in past relevant work. If the claimant satisfies this burden, then the Commissioner must show 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).
A. Plaintiff Allegations of Error
1. ALJ Review of Medical Opinions
Plaintiff contends the ALJ erred in rejecting in part the opinion of Dr. Wampler, who performed a consulting physical examination and found that the Plaintiff had limitations in reaching. Pl. Br. at 4, 7-9, Doc 11. The ALJ evaluated the medical opinions in conjunction with a review of the record.
a. ALJ Review and Findings
"The claimant has the following severe impairments: Obesity, Rheumatoid Arthritis, Bipolar Disorder, Asthma, Hypertension, Depression, Anxiety Disorder, Gastroesophageal Reflux Disease, Obstructive Sleep Apnea, Status Post Bilateral Carpal Tunnel Release. 20 C.F.R. § 404.1520(c)." (Tr. 15).
"The claimant has a history of chronic knee pain and has undergone three arthroscopic surgeries. She also has a documented history of Gastroesophageal Reflux Disease and obstructive sleep apnea and hypertension. Further, the claimant... reported using a CPAP device in 2006." (Tr. 15).
"The claimant also has asthma, and uses a Proventil inhaler to alleviate her symptoms. As noted extensively below, the claimant has presented multiple times to local emergency departments with acute joint pain, which has been diagnosed as rheumatoid arthritis or possible fibromyalgia." (Tr. 15).
"At the hearing, the claimant's attorney noted that the claimant is 63 inches tall and weighs 278 pounds, which equals a Body Mass. Index of 49.2." (Tr. 15).
"The claimant also has a history of mental difficulties, and reported in 2006 that she had been hospitalized four times at Chambersburg Hospital for psychiatric reasons. She carries a diagnosis of Bipolar Disorder II. The claimant also alleges and has testified to symptoms of Anxiety Disorder, noting that she isolates herself while at home and has difficulty interacting with others. She testified that her anxiety causes her to become physically ill. ...