United States District Court, W.D. Pennsylvania
MAURICE B. COHILL, Jr., Senior 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 Marci Ann Butler ("Plaintiff" or "Claimant") for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("SSA"), 42 U.S.C. §§ 1381 et. seq. Plaintiff argues that the decision of the administrative law judge ("AU") should be remanded to the Commissioner either for payment of disability on the current record or for further administrative proceedings and a decision which complies with prevailing legal standards because the ALJ's determination is not supported by substantial evidence. To the contrary, Defendant argues that the decision of the ALJ is supported by substantial evidence, and 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.
For the reasons stated below, the Court will grant Defendant's Motion for Summary Judgment, and deny the Plaintiff's Motion for Summary Judgment.
II. Procedural History
On February 24, 2012, Plaintiff protectively filed a Title II application for a period of disability and disability insurance benefits and also filed a Title XVI application for SSI, (R. at 11), claiming that she became disabled and unable to work beginning January 13, 2012 (R. at 11). On May 16, 2012 the claims were denied (R. at 11). On June 26, 2012, Plaintiff filed a timely written request for a hearing. The hearing was held on May 23, 2013. Present at the hearing were Plaintiff, her attorney, A. Tereasa Rerko, and an impartial vocational expert ("VE") Irene H. Montgomery.
Based on evidence presented at the hearing, Administrative Law Judge, Marty R. Pillion issued an opinion on July 16, 2013. The ALJ found that the Plaintiff had the following severe impairments: obesity, ankylosing spondylosis, panuveitis of the right eye, chronic low back pain, lumbar facet syndrome, bilateral sacroiliitis, uveitis, idiopathic iritis, myopia, gastroenteritis, lumbago, lumbar disc degeneration without myelopathy, lumbar sprain/strain, HLAB27, lumbar radiculopathy, lumbar spondylosis, generalized anxiety disorder, depressive disorder, and sexual identity disorder (R. at 13). However, the ALJ determined that Plaintiff was not disabled under the SSA (R. at 22).
The ALJ concluded that Plaintiff's impairments did not meet or medically equal one of the Listed Impairments found in the SSA, 20 C.F.R. Part 404, Subpart P, Appendix I, (R. at 14), and that Plaintiff had the Residual Functioning Capacity ("RFC") to perform sedentary work except she is limited to occasional balancing, stooping, kneeling, crouching, crawling, and climbing ramps and stairs, no climbing ladders, ropes, or scaffolds, frequent reach, handle, Enger, and feel, no exposure to hazards such as heights or moving machinery, and no exposure to atmospheric conditions such as odors, dusts, gases, or poor ventilation beyond a level typically found in an indoor work environment such as an office or department store. Further, she can only perform tasks requiring occasional reading, and no work requiring binocular vision or depth perception, and is limited to simple routine, repetitive tasks and simple work-related decisions. (R. at 16)
On January 28, 2014 the Appeals Council denied Plaintiff's Request for Review making the ALJ's decision the final decision of the Commissioner (R. at 1-5). Plaintiff filed suit in this Court for judicial review of the Commissioner's decision. Presently before this Court are the parties' cross-motions for summary judgment under Rule 56 of the Federal Rules of Civil Procedure.
III. Medical History
The ALJ reported that the doctors' records used to evaluate claim were: Samuel E. D'Onofrio, University of Pittsburgh Physicians, UPMC Eye Center, Westmoreland Regional Hospital, V. Hema Kumar, M.D., and H. King Harman, Jr., M.D (R. at 101). In addition to these doctors, the record reflected that Plaintiff saw Dr. Malik at the UPMC Arthritis and Autoimmunity Center on a regular basis for epidural injections (R. at 230).
Plaintiff reported taking the following medications: 10 milligrams of escitalopram for depression, naproxen for bones, lorazepam for acid reflux, estradiol for transgenderism, Opana pain pills and Remicade for bones (R. at 39).
In the Disability Determination Explanation, Plaintiff advised the adjudicator that [s]he no longer believes that [s]he has a disabling mental impairment that prevents [her] from working (R. at 78). Furthermore, we found no substantive mental capacity reports on the record. Therefore, claims relating to mental incapacity will not be addressed in our opinion. Our opinion focuses on the Plaintiff's claims related to back pain and eye disease.
On November 10, 2010 Plaintiff had an office visit to her primary case physician, Dr. V. Hema Kumar, M.D. regarding a sore red eye with seepage (R. at 239). Dr. Kumar's impression was conjunctivitis (R. at 239).
On January 5, 2011 Plaintiff attended the Emergency Department of Excela Health Westmoreland Hospital complaining of eye problem of redness and pain. Plaintiff was diagnosed with acute conjunctivitis and was discharged with prescription eye drops (R. at 281).
On January 11, 2012 Plaintiff went to the Emergency Department of Excela Health Westmoreland Hospital with her eye problem. Plaintiff was experiencing a lot of pain and loss of vision (R. at 271). H. King Hartman, Jr., M.D. diagnosed Uveitis, NOS, Idiopathic iritis, Inflammatory pupillary membrane, posterior synedhiae, OD-Hypopyon, AC fibrin, and Myopia (R. at 259). Impression: Severe Panuveitis of the right eye (R. at 271). Plaintiff was referred to Samuel E. Donofrio by Dr. Hartman. Dr. D'Onofrio gave Plaintiff a guarded visual prognosis (R. at 313).
On January 30, 2012 Plaintiff had a physical examination with a diagnosis of musculoskeletal pain and strain (R. at 77). Plaintiff visited the Emergency Department at Excela Health Westmoreland Hospital with back or flank pain (R. at 263). Plaintiff was positive for right midline tenderness upon palpation but did not have limited range of motion and straight leg testing was negative (R. at 265). Diagnosis was probable sacrolitis (R. at 265). Plaintiff was given pain medication and discharged on the same day (R. at 270).
On February 23, 2012 Plaintiff saw Dr. Ashima Malik of the UPMC Arthritis and Autoimmunity Center for a physical exam. Plaintiff was diagnosed with severe disorders of the back - dicogenic and degenerative and non-severe loss of visual acuity (R. at 78). Diagnoses was Ankylosing Spondylitis and Sacroiliitis NEC (R. at 297). Dr. Malik reports that Plaintiff was found to have HLA-B27 and sacro-ilitis on x-rays and she was referred to Rheumatology (R. at 297). Dr. Malik ordered the following plan: "-check hep B, hep C, esr, CRP and CCP. - get X-rays of neck/thoracic land lumbar spine. - get CT scan of pelvis to see extent of erosions so can compare in future. - increase dose of Indocin to 800mg TID scheduled with PPI for inflammatory pain. Continue tit with nasaid's for next 1-2 months. If no response - will need Anti-TNF's. - start physical therapy or ROM and setting up a home exercise program." (R. at 300).
As stated above, Dr. D'Onofrio saw Plaintiff for a comprehensive ocular examination on January 11, 2012. Based on the examination he reports, "As for disability status. Patient will have great difficulty performing any work related tasks involving depth perception. Patient has little to no usable vision in her right eye. Driving, handling heavy equipment, etc. would not be recommended second to her current visual status." (R. at 313). However, On March 19, 2012 Dr. Samuel E. D'Onofrio provided a report which listed no other restrictions for Plaintiff (R. at 311-12).
On April 10, 2012 at CT of the pelvis and abdomen was performed on Plaintiff at Westmoreland Regional Hospital. Findings were generally unchanged and normal. It was only noted that there may be subtle sclerosis on iliac side of both SI joints (R. at 387).
On April 26, 2012 Plaintiff returned to Dr. Malik for back pain. Plaintiff reported pain and stiffness all day and unable to sleep at night. Plaintiff had 10 sessions with physical therapy which she reported did not provide any relief (R. at 691). Plaintiff also reported no improvement on ibuprofen or Naprosyn. Plaintiff has HLAb-27 associated spondyloarthropathy that failed to respond to nsaids (non-steroidal anti-inflammatory drugs) and conservative measures (R. at 693). The plan was to start Humira, and continue Naprosyn until they could get Anti-TNF's. Plaintiff was told to continue physical therapy for range of motion ("ROM") exercises (R. at 693).
April 30, 2012 Plaintiff saw Kelli Sarocky, PA-C for chronic low back pain. Plaintiff rated the pain at 7/10. Plaintiff was awaiting approval to begin Humira (R. at 686). "Patient was significantly tender to even light palpation throughout lumbar spine and bilateral SI joints. No spasms noted." (R. at 688). Plaintiff was hesitant on ROM and ROM and straight leg raise aggravated the pain in the lower extremities bilaterally. Plaintiff had full ROM in lower extremities and strength testing is 5. Patella and Achilles reflexes are 2. Sensation is intact and equal across all dermatomal distributions (R. at 688). Doctor Sarocky recommended discontinuing use of naproxen and Ibuprofen due to ineffectiveness (R. at 688). Plaintiff was prescribed alternative medications of Meloxicam and Tramadol (R. at 688).
Plaintiff underwent a left SI injection on May 4, 2012 but she found no benefit (R. at 677). Dr. Michael Toshok administered the injection with an attempt for 50% pain reduction over the left sacroiliac region. Plaintiff reported a pain level of 6110 on this day (R. at 683).
On May 8, 2012 Plaintiff attended Westmoreland Regional Hospital for a Bone Density Scan of the Spine and Hip to get a baseline reading (R. at 383). The scan was performed due to the diagnosis of ankylosing spondylitis. The Plaintiffs BMD was compatible with normal bone density (R. at 383). A eomparison was performed of the spine to a January 21, 2009 study where degenerative disc status loss was minimal and osteophyte formation and minimal bilateral foraminal encroachment were seen at C5-C6 and C6-C7 (R. at 386). At the thoracic spine there was minimal marginal osteophyte formation and some mild anterior wedging of the T10 and T11 vertebral bodies (R. at 387).
May 16, 2012 Plaintiff returned to Dr. Sarocky, PA-C for a follow up visit for chronic low back pain. The pain was located about the cervical, thoracic, lumbar spine but was most significant along the lumbar spine. The pain does refer along both hips and the anterior inguinal areas. Plaintiff rated the pain as an 8/10 and states it occurs daily (R. at 680). Plaintiff said her pain is aggravated with all forms of motion and is interfering with her activities of daily living (R. at 680). Plaintiff was undergoing physical therapy three ...