United States District Court, W.D. Pennsylvania
TERRENCE F. McVERRY, Senior District Judge.
Anna Marie Von ("Plaintiff") brought this action pursuant to 42 U.S.C. § 1383(c)(3) for judicial review of the decision of the Commissioner of Social Security ("Commissioner"), which denied her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 401-403, 1381-1383(f). The parties have filed cross-motions for summary judgment (ECF Nos. 8, 10), which have been fully briefed (ECF Nos. 9, 11) and, accordingly, are ripe for disposition. For the following reasons, Plaintiff's motion will be GRANTED, and the Commissioner's motion will be DENIED.
Plaintiff was born on August 17, 1961. (R. 46). She left high school in the tenth grade, and has past relevant work experience as a fast food worker and assistant manager. (R. 46). She has not, however, engaged in substantial gainful activity since her amended alleged onset date of March 26, 2010. (R. 23, 28).
A. Medical Evidence
Plaintiff has been treating with her primary care physician, Dr. John Kalata ("Dr. Kalata, Jr.") since before her amended alleged onset date. The record from that period demonstrates that Plaintiff has a history of anemia, for which she required three blood transfusions, and low back pain, which was treated with pain medications and muscle relaxers.
Shortly after Plaintiff's amended alleged onset date, in early April 2010, Dr. Kalata, Jr. diagnosed Plaintiff with chronic lower back pain and anemia. (R. 355). On April 8, 2010, Plaintiff underwent an MRI of her lumbar spine. (R. 440). The MRI revealed degenerative disc disease at L4-L5 and chronic stable perineural cysts in the sacral recess (R. 440).
In August 2010, Plaintiff was referred to an orthopedist for physical therapy. (R. 358). She attended an evaluation with the physical therapist on September 20, 2010, and was scheduled to undergo therapy twice a week for four to six weeks. (R. 483). However, she was discharged on October 1, 2010, with the therapist noting that Plaintiff "subjective [complaints are] inconsistent [with] objective findings" and that she had "poor rehab potential." (R. 483). It was further noted that Plaintiff "demonstrates positive Waddell signs indicating abnormal illness behavior and signs of poor sincerity of effort." (R. 483). At the time of her discharge, Plaintiff maintained that her symptoms were unchanged and that she experienced severe pain for two days following each therapy session (R. 483, 487).
Following her brief stint in therapy, Plaintiff continued to see Dr. Kalata, Jr. for her back pain. In November 2010, she was diagnosed with fibromyalgia and prescribed Savella. (R. 474). The next month, Plaintiff reported that the Savella "helped a great deal." (R. 474). Plaintiff continued to receive routine medication management from Dr. Kalata, Jr. throughout the rest of 2010-2011 until around the time of her administrative hearing in 2012. She was prescribed Vicodin, for pain, as well as a number of other medications. During that time period, she continued to complain of back pain. (R. 471-474). At various points, she also complained of shoulder and knee pain, though these conditions eventually subsided. (R. 469-493).
B. Opinion Evidence
On November 22, 2010, Dr. John Kalata, Sr. ("Dr. Kalata, Sr.) conducted a physical consultative examination at the behest of the state agency. (R. 451). At the time, Plaintiff's chief complaint was chronic back pain. (R. 451). Dr. Kalata, Sr. noted that Plaintiff had complained of experiencing back pain since the age of 24, and since that time, she had suffered several back injuries. (R. 451). Upon examination, Plaintiff did not display any edema or calf tenderness. (R. 454). However, diminished lumbar lordosis, tenderness in the bilateral lumbar paraspinal muscles, and tenderness over the sacroiliac joints were noted. (R. 454). Plaintiff also displayed positive signs in 10 out of the 18 fibromyalgia tender points. (R. 454). Moreover, her cranial nerves were grossly intact and her deep reflexes were � in the upper and lower extremities bilaterally. (R. 454). Her sensation was intact in all four extremities, and she had 4/5 strength in her hip flexors and extensors, as well as her knee flexors and extensors. (R. 454). Dr. Kalata, Sr. observed that pain limited Plaintiff's motion. (R. 454). Straight leg raising was negative, and Plaintiff could not heel walk. (R. 454). Based upon his examination, Dr. Kalata, Sr.'s impressions were: (1) chronic lumbar pain likely secondary to degenerative disc disease, possible lumbar radiculopathy; (2) probable fibromyalgia; (3) chronic anemia; (4) previous history of metromenorrahagia, now status post hysterectomy; (5) lower extremity weakness, likely secondary to low back pain; (6) hypertension; (7) dyslipidemia; (8) diminished visual acuity bilaterally; and (9) poor dentition. (R. 455).
Following his examination, Dr. Kalata, Sr. completed a medical source statement, in which he opined that Plaintiff could frequently lift and carry two to three pounds and occasionally lift and carry 10 pounds. (R. 444). He also opined that Plaintiff could stand and walk one to two hours in an eight-hour workday, and sit three to four hours a day, with frequent breaks and leaning. (R. 444). Furthermore, he found that Plaintiff was limited in pushing and pulling in her lower extremities, could occasionally engage in all postural activities except balancing and climbing, and could not reach. (R. 444-45). Several environmental restrictions were also noted. (R. 445).
Dr. Kalata, Jr. completed his own medical source statement on March 19, 2012. (R. 490-92). He opined that Plaintiff could occasionally lift and/or carry 10 pounds and frequently carry less than 10 pounds. (R. 490). He also noted that Plaintiff could stand/walk for two hours in an eight-hour work day with frequent breaks and sit two hours in a workday, though she would be required to periodically alternate between sitting and standing every 30 minutes to relieve pain or discomfort, which would cause her to be off task for about two to four minutes each time. (R. 491). According to Dr. Kalata, Jr., Plaintiff's ability to push and/or pull in her lower extremities was limited; however, she did not have any manipulative limitations. (R. 491). In addition, he noted, Plaintiff could never climb, crouch, or crawl, but she could occasionally engage in the other postural activities (i.e., balancing, kneeling, and stooping). (R. 491). In closing, Dr. Kalata, Jr. opined that Plaintiff would ...