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Young v. Colvin

United States District Court, M.D. Pennsylvania

September 30, 2014



GERALD B. COHN, Magistrate Judge.

I. Procedural History

On April 30, 2010, Connie Rose Young ("Plaintiff") protectively filed an application for Title II Social Security Disability benefits ("DIB"), and a Title XVI application for Supplemental Security Income ("SSI"), with an alleged onset date of February 15, 2008 (Tr. 226-235, 305).

This application was denied, and on January 24, 2012 and March 20, 2012, a hearing was held before an Administrative Law Judge ("ALJ"), where Plaintiff appeared with counsel and testified, as did medical experts and two vocational experts (Tr. 30-73). On April 12, 2012, the ALJ issued a decision finding that Plaintiff was not entitled to DIB or SSI because Plaintiff could perform light work involving simple, routine, repetitive tasks in a work environment free from fast-paced production, involving simple work-related decisions, few, if any, workplace changes, and no interaction with the public (Tr. 68-69, 20-21). On December 4, 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. 7, 1-5).

On February 1, 2013, 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 May 10, 2013, Commissioner filed an answer and administrative transcript of proceedings. Docs. 5, 6. In July and August 2013, the parties filed briefs in support. Docs. 11, 12. On May 1, 2014, the Court referred this case to the undersigned Magistrate Judge. On May 20, 2014, the parties consented to Magistrate Judge jurisdiction, and Plaintiff notified the Court that the matter is ready for review. 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

A. Background and Hearing Testimony

Plaintiff was 46 years old on her alleged onset date, a "younger individual, " and she became an "individual closely approaching advanced age" on the date of the ALJ's decision (Tr. 47-48, 53). Plaintiff attended school until ninth grade when she became pregnant, is able to communicate in English and has a work history as a factory laborer, machine operator and packer (Tr. 47-48, 68, 281-282). She failed her GED test eight times (Tr. 47-48, 53). According to the vocational expert, Plaintiff's past work was medium to heavy in exertional demands (Tr. 68, 253-254). Her past relevant work as a packer or kettle fryer (Tr. 20). She last worked in February 2008, packing apples for Rice Foods (Tr. 859). She lives with her husband, her 22-year old daughter, and her granddaughter (Tr. 47-48, 222). Plaintiff's husband is employed and the family subsists on his salary (Tr. 859).

During her hearing testimony, Plaintiff denied that she did any cooking, grocery shopping or yard work (Tr. 49). Plaintiff testified that she had a driver's license, but did not visit others or eat in restaurants (Tr. 50). Plaintiff stated that she could bend over and touch her toes and squat to pick up a pen (Tr. 50). Plaintiff thought that she could walk for about 30 minutes before needing to rest and sit for about one hour before needing to change positions (Tr. 50-51). Plaintiff said that she could do laundry and wash the dishes, but that it would take her 6 or 7 hours to finish doing the dishes (Tr. 52-53). Plaintiff stated that she went on vacation when she was able, and had gone camping for one week at Cowans Gap State Park during 2010 (Tr. 50).

In her written statements, Plaintiff reported a less restricted range of daily activities. She wrote that she arose at 7:30 AM in the morning to get her granddaughter off to school (Tr. 260). During the day, Plaintiff said that she played games on the computer, watched television, cleaned the bathroom or mopped the floor, and prepared supper in the late afternoon (Tr. 260). In the evenings, Plaintiff made sure her granddaughter did her homework and showered, and cared for pets (Tr. 261). Plaintiff reported that she cooked frozen food, and that once or twice per week, she prepared a complete meal, which would take her one or two hours (Tr. 261). Plaintiff wrote that she did housecleaning all week, and laundry all day on Sundays (Tr. 262). Plaintiff stated that she continued to drive, went outside daily, and went grocery shopping every other week for one to two hours (Tr. 263-264). She reported that she was able to pay bills and manage her finances (Tr. 263).

B. Relevant Medical Evidence

During 2009, Plaintiff received treatment from Dr. Paul Zeshonsky, her long-term family practitioner at Gettysburg Family Practice (Tr. 255, 553). In January 2009, Plaintiff reported a great deal of chronic pain all over her body (Tr. 555). They discussed the symptoms of depression, and while Plaintiff seemed to give some positive responses for depression symptoms, she nonetheless "vehemently denied" feeling depressed (Tr. 555). Plaintiff declined a referral for a psychiatric consultation, saying that she did not need to see a psychiatrist (Tr. 555). Plaintiff's husband inquired about the possibility of Plaintiff applying for disability, and Dr. Zeshonsky responded that it was his hope that with treatment, Plaintiff would feel "well enough to eventually resume work, " but that short-term disability might be reasonable idea (Tr. 555).

In February 2009, Plaintiff reported ongoing pain from her fibromyalgia, denied that she was depressed, and maintained that she was not able to get back to work (Tr. 553). She stated that she no longer drove due to concentration problems, was anxious at times, and was taking Cymbalta (an anti-depressant medication (Tr. 553). Her musculoskeletal exam revealed multiple trigger points over her upper back scapular area (Tr. 553). Dr. Zeshonsky wrote that Plaintiff was tender to touch in her arms and legs, with inappropriate levels of pain even with minimal pressure (Tr. 553). He assessed Plaintiff with fibromyalgia, suspected depression, and an Amold-Chiari malformation of the brain, grade I (ACM)[1] (Tr. 553). He referred Plaintiff for a rheumatology and a psychiatric consultation (Tr. 553). He prescribed a four-week aquatic physical therapy program for Plaintiff's fibromyalgia, a Vitamin D supplement, Pantoprazole Sodium for acid reflux, and continued her on Cymbalta (Tr. 257, 554).

On February 18, 2009, Dr. Zeshonsky completed a form for purposes of public welfare benefits, attesting that Plaintiff was temporary incapacitated from performing her usual occupation for a period of one year (Tr. 334-335).

During his April 9, 2009 examination, Dr. Zeshonsky wrote that it was difficult to determine whether Plaintiff "truly had a primary fibromyalgia syndrome, " but he thought that her lack of sound sleep was most certainly playing a role in her generalized pain (Tr. 697). He noted that the neurosurgery department did not believe that Plaintiff's ACM was responsible for her issues, although she was found to have a low vitamin D level and was osteopenic (Tr. 559). Dr. Zeshonsky began Plaintiff on Lyrica for her fibromyalgia, thought that she would benefit from treatment for anxiety, and recommended that Plaintiff follow-up with the aquatic physical therapy he had previously ordered (Tr. 697). Plaintiff denied having any psychiatric problems (Tr. 698).

On April 22, 2009, Dr. Johar Shah, a psychiatrist, evaluated Plaintiff at Dr. Zeshonsky's request (Tr. 563-564). She complained of depression and frustration for a long time (Tr. 563). She denied any psychiatric treatment as an adult, and had been taking Cymbalta during the past year (Tr. 563). During the mental status examination, Plaintiff was kempt (Tr. 564). She was dressed appropriately, did not exhibit abnormal movements, and her behavior was described as cooperative (Tr. 564). She maintained good eye contact, her speech was normal in volume and tone (Tr. 564). Plaintiff's mood was depressed, and her affect was restricted (Tr. 564). Her thought process was mainly goal-directed, and without delusions (Tr. 564). She denied hallucinations and suicidal or homicidal ideation. (Tr. 564). Her cognition was intact, and her insight and judgment were fair (Tr. 564). Dr. Shah's impression was Major Depressive Disorder, Recurrent, Without Psychotic Features, Moderate (Tr. 564). He rated Plaintiff's current GAF at 50, which denotes serious symptoms[2] (Tr. 564). Dr. Shah increased Plaintiff's Cymbalta dosage and added Trazadone at bedtime (Tr. 564).

During an August 7, 2009 follow-up, Dr. Zeshonsky noted that Plaintiff had been put on a higher high dose of Cymbalta and begun on Trazodone (Tr. 841). Plaintiff stated her anxiety was "better" (Tr. 841). Plaintiff also reported having "less musculoskeletal aches and pains." although the aches and pains were still present (Tr. 841). Dr. Zeshonsky again recommended that Plaintiff follow-up with the aquatic physical therapy he had previously ordered (Tr. 842).

At an initial assessment session with social worker Kathleen Chapin on May 13, 2009, Plaintiff explained that her father was a very abusive alcoholic. She and her mother and brother slept together in one bedroom with the door padlocked and the windows nailed shut. She reported having nightmares about her father's abuse. Plaintiff told Ms. Chapin that her memory was very bad and she gets lost going to see her doctor. On mental status examination, Plaintiff was depressed, anxious, angry, and agitated. She reported getting only about an hour of sleep at night. Her memory and concentration were impaired. Her appetite and energy were decreased. Her insight and judgment appeared to be poor (Tr. 567). Ms. Chapin's diagnosis was Major Depressive Disorder, recurrent, without psychotic features, moderate and Anxiety Disorder, NOS. Psychosocial stressors - Plaintiff's medical and mental health issues - were considered severe. Her GAF was 50 (Tr. 566).

On August 11, 2009, Dr. Jennifer Wilson, a state agency physician, completed a physical residual functional capacity assessment, based upon Plaintiff's diagnoses as fibromyalgia, lumbar degenerative disc disease, and all of her other alleged impairments (mild cerebellar tonsillar ectopia, vitamin D deficiency, osteopenia, and a history of diverticulits, obesity, and headaches) (Tr. 568-574). According to Dr. Wilson, in an eight hour workday, Plaintiff could sit for a total of about six hours and stand/walk for a total of about six hours, and lift and carry, and push and pull 10 pounds frequently and 20 pounds occasionally (Tr. 568-574).

On September 30, 2010, Joseph Levenstein, Ph.D., performed a consultative psychological examination (Tr. 859-865). On September 30, 2010, when Plaintiff presented to Dr. Levenstein for a state agency-arranged clinical psychological disability evaluation, he noted that she was under the care of his colleague, Dr. Shah for medication management. Plaintiff described a troubled childhood involving physical and emotional abuse from an alcoholic parent (Tr. 861). She reported that she was taking Cymbalta, prescribed by Dr. Shah (Tr. 860). She also reported smoking 2 packs of cigarettes per day and drinking one or two pots of coffee per day (Tr. 860). Plaintiff stated that she hadn't cooked in three years because she could not remember the recipes (Tr. 860). She felt unmotivated to clean the house and her husband complained about it (Tr. 860).

On a scale of 1 to 10, Plaintiff reported that her fibromyalgia pain fluctuated from a low of 3 to a high of 10, and was typically at six or seven (Tr. 860). Dr. Levenstein concluded that Plaintiff was experiencing significant depression and anxiety (Tr. 864). He speculated that she also had post-traumatic stress disorder and a panic disorder (Tr. 864). He opined that Plaintiff could understand, retain, and follow simple one-step instructions (Tr. 864). He thought that she could not sustain attention sufficiently to complete simple, repetitive tasks (Tr. 864). He diagnosed post-traumatic stress disorder, panic disorder with agoraphobia, major depressive disorder, and ...

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