United States District Court, M.D. Pennsylvania
Docs. 1, 6, 7, 8, 11.
GERALD B. COHN, Magistrate Judge.
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying the application of Plaintiff Jan Christine Jones for disability insurance benefits ("DIB") under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). In this case, the ALJ concluded that Plaintiff did not meet a Listing, was not able to perform her past relevant work, but was able to perform work in the national economy. Plaintiff challenges only the ALJ's Listing assessment. She does not challenge the residual functional capacity assessment, credibility findings, assignment of weight to the medical evidence, or step five conclusion. However, in order to qualify for a Listing, Plaintiff must meet all of the stringent medical criteria. Plaintiff failed to establish a diagnosis of lumbar spinal stenosis, an inability to ambulate, or muscle weakness, all of which are required for Listing 1.04(C). Plaintiff failed to establish that her depression was sufficiently persistent to qualify under Listing 12.04, and also failed to establish that she had marked impairments in at least two of the Paragraph B criteria. Because Plaintiff raises no other issues on appeal, substantial evidence supports the ALJ's decision.
II. Procedural Background
On February 25, 2010, Plaintiff filed an application for DIB under Title II of the Act. (Tr. 282-88). On April 28, 2010, the Bureau of Disability Determination denied this application (Tr. 135, 153-56), and Plaintiff filed a request for a hearing on June 29, 2010. (Tr. 157-58). On June 29, 2011 and February 23, 2012, an ALJ held a hearing at which Plaintiff-who was represented by an attorney-and a vocational expert ("VE") appeared and testified. (Tr. 30-134). On March 30, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 9-29). On May 5, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 7-8), which the Appeals Council denied on June 25, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-5).
On August 15, 2013, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On October 23, 2013, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 6, 7). On November 11, 2013, Plaintiff filed a brief in support of her appeal ("Pl. Brief"). (Doc. 8). On January 14, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 11). On April 30, 2014, the Court referred this case to the undersigned Magistrate Judge. Both parties consented to the referral of this case for adjudication to the undersigned on June 16, 2013, and an order, and an order referring the case to the undersigned for adjudication was entered on July 3, 2014. (Doc. 13, 14).
III. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Johnson v. Commissioner of Social Sec. , 529 F.3d 198, 200 (3d Cir. 2008); Brown v. Bowen , 845 F.2d 1211, 1213 (3d Cir. 1988). 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 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 from 20 C.F.R. Part 404, Subpart P, Appendix 1; (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 claimant. 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 13, 1965 and was classified by the regulations as a younger individual through the date of the ALJ decision. 20 C.F.R. § 404.1563. (Tr. 313). She has a high school and college education and past relevant work as a Bus Driver, Teacher Aide II, Job Development Specialist, and Case Worker. (Tr. 23).
The only issue raised by Plaintiff regarding her physical impairments is that the ALJ should have found that she met or equaled Listing 1.04(C), which requires:
1.04 Disorders of the spine (e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disk disease, facet arthritis, vertebral fracture), resulting in compromise of a nerve root (including the cauda equine) or the spinal cord. With:
C. Lumbar spinal stenosis resulting in pseudoclaudication, established by findings on appropriate medically acceptable imaging, manifested by chronic nonradicular pain and weakness, and resulting in inability to ambulate effectively, as defined in 1.00B2b;
20 C.F.R. Part 404, Subpart P, Appendix 1, Section 1.04(C). Consequently, the Court will limit its discussion to the medical evidence of Plaintiff's physical impairments pertinent to those factors.
On February 9, 2010, Plaintiff injured her back when she fell on ice. (Tr. 344). She went to her primary care physician that day, but refused to get undressed for examination. (Tr. 346). She had good leg strength with "no leg weakness." (Tr. 354). She had tenderness in her back and buttocks. (Tr. 346). She had X-rays, which were normal. (Tr. 355, 367). On February 18, 2010, she reported neck pain that radiated into her buttocks. (Tr. 344).
On April 2, 2010, Plaintiff continued to complain of back pain, including pain on forward bend. (Tr. 352). She denied pain in either leg. (Tr. 352). On April 19, 2010, notes indicate that an MRI of her lumbar spine was entirely normal, and she was prescribed physical therapy. (Tr. 353, 370). The MRI report specifically stated "there is no evidence of... spinal stenosis." (Tr. 370).
Plaintiff had a physical therapy evaluation on May 21, 2010. (Tr. 390). She "ambulate[d] with a stiff pattern, but towards the end of the evaluation has more antalgia with limited [left leg] weight bearing, and shifted away from the left." (Tr. 390). Plaintiff had "difficulty with transitional movements supine to sit to standing to sidelying." (Tr. 390). Her range of motion was "very limited in all directions." (Tr. 390). Her pain would radiate into her leg, but only on the left side. (Tr. 390). At physical therapy on May 28, 2010, Plaintiff reported that she could walk two to three blocks, at most. (Tr. 394). On June 1, 2010, she "walk[ed] into therapy with straight posture, no antalgia." (Tr. 395). On June 9, 2010, Plaintiff reported radiating pain, but only into her left hip. (Tr. 396). At physical therapy on June 28, 2010, Plaintiff reported that she was walking to therapy, that she thought the exercise was good, and that she was not really hurting until she got there. (Tr. 401). She reported radiating pain, but only on the left side. (Tr. 401). On July 2, 2010, Plaintiff indicated that she was continuing to walk to therapy, although she had to stop and stand to rest. (Tr. 402). On July 9, 2010, she indicated numbness, but only in her left leg. (Tr. 403). Plaintiff was discharged from physical therapy on July 15, 2010 with her goals not met. (Tr. 404-05).
On May 26, 2010, Plaintiff presented to Keystone Family Medicine complaining of gastrointestinal problems and low back pain. Although she described her pain as a 9.5 out of 10 and was very careful about getting in and out of her chair, the nurse practitioner observed:
On discharge the nurse says she saw her drop a magazine and she picked it up without bending her knees and she did that briskly. I also went out to see her get into her car and she put her butt on the seat and brought her legs up all in one swift motion and seemed to have no difficulty getting into the car.
On July 25, 2010, Plaintiff presented to the emergency room at Chambersburg Hospital complaining of back pain. (Tr. 388). She indicated that she had numbness in her left arm and left leg. (Tr. 388). However, her strength was 5/5 throughout. (Tr. 388). There was "no atrophy." (Tr. 388).
On July 31, 2010, an MRI of Plaintiff's cervical spine indicated "Mild multilevel disc bulge extending from C3-4 through C6-7. At C5-6 levels, mild right paracentral disc bulge can be seen with slight compression of thecal sac and right nerve root." (Tr. 386).
On August 7, 2010, Plaintiff presented to the emergency room at Chambersburg Hospital complaining of back pain. (Tr. 385). Notes indicate that she had an MRI that indicated disc herniation. (Tr. 385). She indicated that her medications were not helping her, but she had normal strength and denied weakness. (Tr. 385). Notes indicate the doctor noted "I am not sure I have much to offer this patient" and Plaintiff was discharged home. (Tr. 385).
On August 9, 2010, Plaintiff presented to Keystone Family Medicine complaining of back pain that radiated into both legs. (Tr. 501). She indicated that activities of daily living aggravated her pain, and that standing relieved her pain. (Tr. 501). On August 10, 2010, Plaintiff presented to Keystone Family Medicine for forms to be filled out for her Medical Access card. (Tr. 496). She had back pain, but was negative for muscle weakness. (Tr. 496).
On October 12, 2010, Plaintiff was evaluated by Dr. Barbara Haeckler at Keystone Family Medicine. (Tr. 490). She was "very upset and angry from the time [Dr. Haeckler] ...