United States District Court, M.D. Pennsylvania
MALACHY E. MANNION, District Judge.
Plaintiff Edward Hiles has filed this action pursuant to 42 U.S.C. §405(g) seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying his claim for social security disability insurance benefits and supplemental security income benefits.
Disability insurance benefits are paid to an individual if that individual is disabled and "insured." Hiles met the insured status requirements of the Social Security Act through December 31, 2015. Tr. 14. Therefore, to be entitled to disability insurance benefits, Hiles must establish that he suffered from a disability on or before that date. 42 U.S.C. §423(a)(1)(A).
Hiles protectively filed his applications for social security disability insurance benefits and supplemental security income benefits on August 24, 2010 and December 29, 2010, respectively, with an amended date of disability of February 14, 2011. Tr. 12. Hiles has been diagnosed with migraines, right shoulder subacromial impingement status post tendon tear repair, degenerative disc disease of the lumbar and cervical spine, intermittent vertigo, carpal tunnel syndrome status post release, posttraumatic stress disorder ("PTSD"), major depressive disorder, and personality disorder. Tr. 14-15. On January 12, 2011, Hiles' applications were denied by the Bureau of Disability Determination. Tr. 33, 39.
On February 25, 2011, Hiles requested a hearing before an administrative law judge ("ALJ"). Tr. 30. The ALJ conducted a hearing on April 30, 2012, where Hiles was represented by an attorney. Tr. 878-922. On June 5, 2012, the ALJ issued a decision denying Hiles' applications. Tr. 12-23. On April 30, 2013, the Appeals Council declined to grant review. Tr. 5. Hiles subsequently filed a complaint before this Court on July 1, 2013, and this case became ripe for disposition on February 20, 2014, when Hiles filed a reply brief.
Hiles appeals the ALJ's decision on three grounds: (1) the residual functional capacity determination was not based on substantial evidence, (2) the ALJ erred in her evaluation of the available medical opinion evidence, and (3) the ALJ erred in her determination at Step Three. For the reasons set forth below, the decision of the Commissioner is affirmed.
Statement of Relevant Facts
Hiles was forty years of age at the time of the ALJ's decision; he has a high school education and is able to read, write, speak, and understand the English language. Tr. 21, 137. Hiles' past relevant work includes work as a kitchen helper, which is classified as medium, unskilled work, and as a warehouse worker, which is also medium, unskilled work. Tr. 918-19.
A. Hiles' Headaches and Vertigo
Hiles began experiencing symptoms of vertigo as early as May 15, 2007, well prior to the relevant period. Tr. 290-91. MRA and MRI scans were performed on his brain that same day, with neither revealing any significant abnormalities. Tr. 292. Hiles continued presenting to his treating physicians at Myerstown Family Practice throughout 2009 with complaints of continuing vertigo. Tr. 298-99, 322-225, 327-28. His treating physicians diagnosed him with "vertigo benign paroxysmal position." Tr. 322. An October 14, 2009 MRI of the brain revealed sinus and mastoid inflammatory disease, but was otherwise grossly negative. Tr. 326.
On November 2, 2009, Hiles reported to his treating physician that he was "doing fantastically well as he had... right ear tube replace[ment] per Dr. Masaros and now the vertigo is essentially much better." Tr. 329. It was noted that Hiles' vertigo was "resolved after the ear tube replaced." Id . However, at a December 8, 2009 neurological consultation with David Gill, M.D., Hiles reported that his vertigo had returned. Tr. 372. Dr. Gill noted that Hiles "did have a tube placed in his right tympanic membrane mid to end of October, which gave him 4 to 5 days of complete relief of his vertigo." Id . Hiles reported many near falls and stated that Meclizine helped with the vertigo, but caused tiredness. Id . A physical and neurological examination was normal. Tr. 373. Hiles also reported migraines accompanied by nausea and vomiting, although he noted that "ibuprofen and promethazine are quite helpful at relieving them after a few hours." Id.
During a January 4, 2010 appointment with Dr. Mesaros, Hiles reported that he was still experiencing symptoms of vertigo, particularly when he turned his head. Tr. 352. On March 1, 2011, Hiles returned to Dr. Mesaros with continued vertigo. Tr. 471. An MRI did not suggest any abnormality or mass lesion, and an ENG did not reveal any inner ear pathology. Id . Dr. Masaros opined the he was "a little stumped [as to] why [Hiles] has had persistent vertigo." Id.
On March 28, 2011, Hiles presented to Jonas Sheehan, M.D. and David Black, PA-C with complaints of persistent vertigo. Tr. 601. Dr. Sheehan noted that Hiles had twelve reconstructive surgeries on his right ear, and opined that "it is most likely that he is having sequelae from his surgeries causing his vertigo problem." Id . Hiles continued seeking treatment for his vertigo from Myerstown Family Practice through October 2011. Tr. 441-50, 505-06.
Hiles also frequently complained of headaches beginning as early as 2009. Tr. 322. Throughout 2009 and 2010, Hiles told his treating physicians that his headaches were somewhat controlled by medication. Tr. 322, 324, 329, 335, 338, 341, 345. By early 2011, Hiles was continuing to experience headaches, with only some relief provided by ibuprofen and other over-the-counter medications. Tr. 438, 505.
On April 28, 2011, Hiles was examined by Virginia Thompson, CRNP for a pain management consultation. Tr. 545-48. Hiles complained of ongoing headaches ranging from a three out of ten pain at their best, to ten out of ten pain at their worst. Tr. 545. He stated that Aleve was "quite helpful for him" and declined occipital nerve blocks. Tr. 547. Ms. Thompson noted "significant tenderness to palpation, most notably over the right occipital area, which recreated [Hiles'] usual headache[.]" Tr. 546. Otherwise, Hiles' physical examination was normal and Ms. Thompson did not prescribe any medication. Tr. 546-47.
On July 20, 2011, Hiles was examined by Evan Freeman, D.O. Tr. 542. Hiles stated that he continued to experience headaches once to twice per day, for approximately three or four days each week. Id . These headaches were generally preceded by vertigo and accompanied by sensitivity to light and sound. Id . When he experienced headaches, Hiles would take an ibuprofen and lie down; after one hour he would feel better. Id . A physical inspection was normal, and Dr. Freeman opined that Hiles' pain was likely related to migraine headaches. Tr. 543.
On August 4, 2011, Hiles returned to Dr. Gill with continuing headaches. Tr. 579. Hiles reported that ibuprofen provided "mild-to-moderate" relief for his headaches, but did not relieve them completely. Id . Physical, neurological, and sensory examinations were normal. Tr. 580. Dr. Gill prescribed an abortive medication, Tompamax, to alleviate Hiles' migraine headaches. Tr. 582.
B. Hiles' Mental Impairments
Throughout the relevant period, Hiles was prescribed psychiatric medications by his treating physicians at Myerstown Family Practice. Tr. 438-39, 441-43. Hiles generally complained of depression, PTSD, stress, and relationship issues. Id . Hiles declined to see a psychiatrist because he could not afford such treatment, but reported feeling "somewhat" better with Effexor. Tr. 439, 443.
On February 14, 2011, Hiles underwent a clinical assessment with a therapist. Tr. 479-84. Hiles was depressed and anxious with a restricted range of affect. Tr. 483. He was cooperative, had normal speech, a clear and coherent thought process, and demonstrated fair impulse control and good insight. Id . Hiles was assigned a GAF score of 42. Tr. 484.
On August 18, 2011, Hiles presented to Anne Dall, M.D. for an initial psychiatric evaluation. Tr. 474-76. Dr. Dall noted that Hiles' "medications are helping somewhat, but he still describes a lot of ongoing symptoms." Tr. 474. Hiles described difficulty focusing and concentrating, and reported flashbacks, explosive mood, poor sleep, anhedonia, feelings of guilt, impaired energy, a loss of interests and motivation, irritability, and anxiety. Id . Hiles was cooperative with a constricted affect and had no psychomotor agitation or retardation. Tr. 475. ...