United States District Court, M.D. Pennsylvania
For Elson Casiano, Plaintiff: Steven M. Rollins, LEAD ATTORNEY, Rollins Law Office, Harrisburg, PA.
For Carolyn W Colvin, Commissioner of Social Security, Defendant: Mark.E. Morrison, U.S. Attorney's office - Social Security, Harrisburg, PA.
William J. Nealon Jr., United States District Judge.
On August 13, 2013, Plaintiff, Elson Casiano, filed this instant appeal under 42 U.S.C. § 405(g) for review of the decision of the Commissioner of the Social Security Administration (" SSA") denying his application for disability benefits (" DIB") and supplemental security income (" SSI") under Titles II and XVI, respectively, of the Social Security Act, 42 U.S.C. § § 401 et seq., 1381 et seq. (Doc. 1). The parties have fully briefed the appeal. For the reasons set forth below, the decision of the Commissioner denying Plaintiffs applications for DIB and SSI will be vacated.
Plaintiff protectively filed his application for DIB on November 6, 2009, and his application for SSI on April 5, 2010. (Tr. 18). These claims were initially denied by the Bureau of Disability Determination (" BDD") on July 28, 2010. (Tr. 18). On August 20, 2010, Plaintiff filed a written request for a hearing before an administrative law judge. (Tr. 18). A hearing was held on April 5, 2012 before administrative law judge Randy Riley (" ALJ"), at which Plaintiff, a vocational expert, Paul Anderson (" VE"), and medical expert, Stuart Gitlow, M.D. (" ME"), testified. (Tr. 18). On April 18, 2012, the ALJ issued a decision denying Plaintiff's claims because, as will be explained in more detail infra, Plaintiff could perform a full range of light work with no overhead reaching, occasional decision-making and changes in routine work setting, no interaction with the public, and occasional interaction with supervisors and coworkers with no tandem tasks. (Tr. 24-25).
On May 25, 2012, Plaintiff filed a request for review with the Appeals Council. (Tr. 13). On June 18, 2013, the Appeals Council concluded that there was no basis upon which to grant Plaintiff's request for review. (Tr. 1-3). Thus, the ALJ's decision stood as the final decision of the Commissioner.
Plaintiff filed the instant complaint on August 13, 2013. (Doc. 1). On November 13, 2013, Defendant filed an answer and transcript from the SSA proceedings. (Docs. 9 and 10). Plaintiff filed a brief in support of his complaint on January 16, 2014. (Doc. 13). Defendant filed a brief in opposition on February 20, 2014. (Doc. 14). Plaintiff filed a reply brief on March 4, 2014. (Tr. 15).
Plaintiff was born in the United States on September 9, 1971, and at all times relevant to this matter was considered a " younger individual"  whose age would not seriously impact his ability to adjust to other work. 20 C.F.R. § 404.1563(c); (Tr. 256).
Plaintiff did not obtain either his high school diploma or GED, and can communicate in English. (Tr. 42, 260, 262). His employment records indicate that he previously worked as a supervisor at a gas station and a warehouse. (Tr. 286-287). The records of the SSA reveal that Plaintiff had earnings in the years 1987 to 2004. (Tr. 242). His annual earnings range from a low of no earnings in 1991, 1993 and 2003, and from 2005 to 2011, to a high of twenty-nine thousand eight hundred sixteen dollars and forty-three cents ($29, 816.43) in 2000. (Tr. 242).
Plaintiff's alleged disability onset date is December 31, 2002. (Tr. 262). The impetus for his claimed disability is a combination of mental health impairments, diabetes, and hypertension. (Tr. 261). In a document entitled " Function Report - Adult" filed with the SSA in May of 2010, Plaintiff indicated that he " stayed where he [could]" in terms of living arrangements. (Tr. 200). He noted that he did not take care of any other people or animals, slept well, sometimes prepared his own meals, did not do house or yard work, was able to drive a car and ride a bicycle, could go out alone, and shopped for food, medicine, and clothes. (Tr. 276-278). Regarding his personal care, he sometimes would go days without bathing, getting dressed, caring for his hair, shaving, or feeding himself. (Tr. 276). When asked to check items which his " illnesses, injuries, or conditions affect, " Plaintiff did not check lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, hearing, stair climbing, seeing, memory, or using hands. (Tr. 280).
Regarding his concentration and memory, Plaintiff needed special reminders " some days" to take care of his personal needs and to take his medicine. (Tr. 277). He could count change and pay bills, but did not handle a savings account or use a checkbook because he did not have either one. (Tr. 278). He stated he did not finish what he started " as often as [he felt he] should, " and that he did not follow written instructions well, but that he could follow spoken instructions " ok." (Tr. 280).
Socially, Plaintiff watched television and did " not really" spend time with others. (Tr. 279). He reported that he " better not say" whether he had problems getting along with family, friends, neighbors, or others. (Tr. 280). He stated that he did not get along with authority figures, and that he had been fired due to problems getting along with other people. (Tr. 281). He did not handle changes in routine or stress well. (Tr. 281).
At his hearing, Plaintiff alleged that the following combination of physical impairments prevented him from being able to work since December of 2002: past substance abuse, back pain, Antisocial Personality Disorder, Mood Disorder, depression, hypertension, and diabetes. (Tr. 46-48, 53-55). He testified that he would go weeks when he would shower " fine, " but there would also be times during which he would not shower for five (5) to six (6) days in a row. (Tr. 43). He shopped for groceries, cooked his meals, and drove a car. (Tr. 43). His mother did his laundry and cleaned his house. (Tr. 43). Aside from his parents visiting him, he did not see any friends or family because he had " no interest in fun" and the majority of his day was spent sleeping and watching television. (Tr. 44). He testified that he did not drink alcohol or use illegal drugs, that he had been sober for over two (2) to three (3) months, and that his longest period of sobriety was thirteen (13) years. (Tr. 45, 48). He smoked two and a half (2 1/2) packs of cigarettes a day. (Tr. 46).
Regarding functional limitations, Plaintiff testified that if he dropped something, he was unable to bend down and pick it up due to back pain. (Tr. 44-45). He had no problems overhead reaching with his left arm, but could only raise his right arm up to chest level. (Tr. 45). He experienced side effects from his medicine, including shortness of breath, a dry cough, and frequent urination. (Tr. 46-47). He also experienced difficulty sitting for too long or standing still due to a diabetic neuropathy. (Tr. 54).
Due to his personality and mood disorders, he had difficulty taking orders from others, had issues with work attendance, had gotten into fights with people because he could not get along with them, had difficulty controlling his temper, which caused him to be fired from several jobs, experienced mood swings, was easily irritated, experienced paranoia that people were watching him, held onto knives in order to " feel safe, " engaged in domestic violence against his wife, and attacked police officers and government property. (Tr. 48-51). He testified that his mental health medications did not fully work, and that he had still experienced anxiety and mood swings. (Tr. 52).
His diabetes was not under control due to medication non-compliance as a result of Plaintiff's forgetfulness. (Tr. 53). He also experienced a neuropathy from his hips down to both legs as a result of his diabetes that made Plaintiff feel like he was " standing on hot charcoal" and that there were " ants  walking over [his legs]." (Tr. 53). His diabetes also caused blurry vision and memory problems. (Tr. 54).
On September 18, 2004, Plaintiff presented to the ER at Pinnacle Health for shortness of breath. (Tr. 421). Plaintiff stated that he felt he was having a reaction to increased psychosocial stressors, and did not want to talk about his drug abuse. (Tr. 422). He was diagnosed with impaired psychosocial coping mechanisms, and was discharged after verbally contracting that he was not suicidal or homicidal. (Tr. 422).
On October 12, 2004, Plaintiff had an appointment at Northwestern Human Services (" NHS"). (Tr. 554). He presented with anxiety, depression, and anger control issues. (Tr. 554). He reported that he was unable to sleep or concentrate, had lost interest in interacting with others, and was frequently agitated, explosive and sad. (Tr. 554). The treatment notes from this visit are largely illegible. (Tr. 554).
On January 3, 2005, Plaintiff had an appointment at NHS. (Tr. 553). Plaintiff reported that he was anxious and depressed, had trouble controlling his emotions, and had been using crack cocaine. (Tr. 553). The treatment notes from this visit are illegible. (Tr. 553).
On January 10, 2005, Plaintiff had an appointment at NHS. (Tr. 552). Plaintiff reported that he continued having difficulty sleeping, mood swings, and agitation. (Tr. 552). His exam noted appropriate grooming, cooperative behavior, normal speech, mood, thought and affect, and no suicidal or homicidal ideations. (Tr. 552). His treatment plan included having a psychiatric evaluation, and addressing his depression. (Tr. 552).
On January 10, 2005, Plaintiff presented to the Edgewater Psychiatric Center for an initial psychiatric evaluation with Edward Coronado, M.D., due to complaints of suicidal thoughts and drug use. (Tr. 318). The " History of Present Illness" (" HPI") section from this visit stated that Plaintiff was separated from his wife, had four (4) children and a ninth grade education, and was unemployed. (Tr. 318). Plaintiff stated that he had been using drugs for a couple of months on a daily basis and drank alcohol episodically, but stopped sniffing cocaine before September of 2004. (Tr. 318). He had previously been incarcerated for cocaine possession in the 1980s, and he was on probation for two (2) years at the time of the appointment for theft. (Tr. 318). He reported having a depressed mood and mood swings that caused difficulty falling asleep and getting out of bed, a lack of appetite, and suicidal thoughts, but he denied feeling hopeless, helpless, or worthless, having suicidal plans, manic symptoms, hallucinatory experiences, or any delusions. (Tr. 318). He had been attending psychotherapy sessions for " some time." (Tr. 318). Plaintiff's exam noted that his speech was coherent, his eye contact was good, his appearance was clean and groomed, his mood was cooperative and pleasant, his affect was blunted, his thoughts were coherent and goal-directed, his thought content lacked hallucinations and delusions, his immediate and remote memory were intact, he was oriented to time and place, and his fund of knowledge was normal. (Tr. 320). His Axis I diagnostic impression was depression and cocaine use, and his Global Functioning Assessment (" GAF") was a sixty (60). (Tr. 320). Dr. Coronado prescribed Wellbutrin for depression, advised that Plaintiff continue with psychotherapy and attend drug treatment group sessions, and scheduled a follow-up for two (2) weeks. (Tr. 321).
On January 17, 2005, Plaintiff presented to the ER at Pinnacle Health for back pain that began after carrying a heavy box. (Tr. 417). Plaintiff was diagnosed with a low back strain and sprain, and was prescribed Ultram. (Tr. 418).
On January 24, 2005, Plaintiff had an appointment at NHS. (Tr. 551). He reported that he was experiencing mood swings, depression, anxiety, and difficulty with relationships. (Tr. 551). His exam revealed appropriate grooming, cooperative behavior, normal speech, mood, thought, and affect, and no suicidal or homicidal ideations. (Tr. 551). His treatment plan included continuing individual therapy. (Tr. 551).
On January 24, 2005, Plaintiff had another appointment with Dr. Coronado. (Tr. 316). Plaintiff was described as having a clean appearance, a blunted affect, a depressed mood, a normal appetite, insomnia, and a normal speech and thought pattern, and was compliant with his medicine. (Tr. 316). Dr. Coronado increased Plaintiff's Wellbutrin prescription. (Tr. 316).
On January 31, 2005, Plaintiff had an appointment at NHS. (Tr. 550). Plaintiff reported that his sleep had improved, and he denied depressed feelings. (Tr. 550). His exam revealed appropriate grooming, cooperative behavior, normal speech, mood, ...