United States District Court, M.D. Pennsylvania
PATTY A. DUVALL-DUNCAN, Plaintiff,
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
REPORT AND RECOMMENDATION TO VACATE THE DECISION OF THE COMMISSIONER AND REMAND THE CASE TO THE COMMISSIONER FOR FURTHER PROCEEDINGS Docs. 1, 5, 6, 7, 8, 9
GERALD B. COHN, Magistrate Judge.
REPORT AND RECOMMENDATION
I. Procedural Background
On October 2, 2009, Patty A. Duvall-Duncan ("Plaintiff") filed an application for Title II Social Security Disability benefits, with a date last insured of December 31, 2011,  and with an onset date of May 2, 2006. (Administrative Transcript (hereinafter, "Tr."), 14, 356-362). Plaintiff's claim was denied at the initial level of administrative review. An administrative law judge (ALJ) held four administrative hearings on June 2, 2011; November 16, 2011; February 23, 2012; and May 31, 2012; during which Plaintiff, who was represented by counsel, an impartial medical expert, and a vocational expert testified (Tr. 35-111, 113-25, 127-39, 141-77). On June 20, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 11-34). On November 11, 2013, the Appeals Council denied Plaintiff's request for review, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner ("Defendant"). (Tr. 1-5).
On January 4, 2014, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) and pursuant to 42 U.S.C. § 1383(c)(3), to appeal a decision of the Commissioner of the Social Security Administration denying social security benefits. Doc. 1. On March 13, 2014, the Defendant filed an answer and an administrative transcript ("Tr.") of proceedings. Doc. 5, 6. On April 25, 2014, Plaintiff filed a brief in support of the appeal ("Pl. Brief"). Doc. 7. On May 30, 2014, Defendant filed a brief in response ("Def. Brief"). Doc. 8. Plaintiff filed a brief in reply ("Pl. Reply") on June 13, 2014. Doc. 9. On November 5, 2014, the date that a claimant meets the requirements of being insured is commonly referred to as the "date last insured."
Court referred this case to the undersigned Magistrate Judge.
II. Relevant Facts in the Record
Plaintiff was born on August 17, 1968, and thus was classified by the regulations as a younger person through the date of the ALJ decision on June 20, 2012. (Tr. 358); 20 C.F.R. § 404.1563(c). The highest grade Plaintiff completed in school was the eighth grade followed by obtaining a GED. (Tr. 91). Plaintiff returned to vocational school at around the age of nineteen. (Tr. 91). Plaintiff's past relevant work includes working as a nurse assistant. (Tr. 19, 1131, 1140). On May 2, 2006, Plaintiff was involved in a car accident. (Tr. 487, 493). Plaintiff alleges disability due to a combination of impairments including degenerative disc disease; post-traumatic stress disorder (PTSD); and pain-related depression and anxiety. Pl. Brief at 1; (Tr. 22, 363, 381, 414). The ALJ found the following impairment to be severe: drug dependence. (Tr. 17). The ALJ found that obesity, lumbar disc disease, and cervical disc disease were non-severe. (Tr. 17).
A. Relevant Treatment History and Medical Opinions
1. Mental Health Records
On December 6, 2007, Dr. Razvan Vaida detailed Plaintiff's medical and psychiatric history and symptoms, ultimately diagnosing Plaintiff with PTSD. (Tr. 654-656). On May 28, 2009, Erik Sprohge, Ph.D., a consultative psychologist, examined Plaintiff and rendered a diagnosis of PTSD. (Tr. 662-71). Dr. Sprohge reported Plaintiff's history, including events and signs that related to PTSD, found her to be a "generally reliable historian, " and confirmed a diagnosis of PTSD. (Tr. 662-666). On July 15, 2009, Michael Suminski, Ph.D., a state agency psychologist, completed a "Psychiatric Review Technique" and concluded that Plaintiff had a medically determinable impairment of PTSD. (Tr. 688).
In a consultative examination report dated May 5, 2010, John Tardibuono, D.Ed., reviewed a series of psychiatric progress notes from July 20, 2009, through January 21, 2010, which listed a diagnosis of PTSD and later confirmed a diagnosis of PTSD. (Tr. 928, 930). In a letter dated June 24, 2010, Plaintiff's treating psychiatrist, Dr. Vaida detailed that she had been treating Plaintiff for PTSD symptoms since December 06, 2007. (Tr. 1136). Dr. Vaida stated that Plaintiff's PTSD symptoms manifested in the form of panic attacks while driving, recurrent distressful thoughts about the accident due to anxiety, and avoiding reminders of her previous car accident. (Tr. 1136). Dr. Vaida opined that Plaintiff appeared to "fall under the category of people with chronic PTSD and she is likely to continue to struggle with PTSD symptoms for years to come." (Tr. 1136).
Plaintiff repeatedly complained of panic attacks, poor sleep, verbal and physical outbursts, mood swings, depression, and anxiety. See e.g., (Tr. 631-657). For example, in a record dated December 24, 2008, Plaintiff reported experiencing anxiety attacks four times a week and stated that she did not drive as a result of the anxiety. (Tr. 634). In a progress note dated October 10, 2010, Plaintiff's treating psychiatrist opined that Plaintiff's prognosis was poor due to chronic pain which caused depression. (Tr. 637).
Regarding Plaintiff's cognitive limitations, Dr. Vaida observed that Plaintiff had limited abstraction skills and poor short-term memory, detailing that Plaintiff's ability to recall after a few minutes required giving her three hints. (Tr. 656). On May 28, 2009, examining psychologist Dr. Erik Sprohge opined that Plaintiff's abstraction was "fair"; she could perform a simple calculation, but could only name two of the last four presidents; Plaintiff could not do "serial seven subtractions" beyond 100 correctly; and although she could repeat four digits going forward, she could only repeat two digits going backwards, and she interjects a new number when trying to complete the three digits backwards. (Tr. 665-666). Based on Plaintiff's responses to hypotheticals Dr. Sproghe' concluded that Plaintiff's social judgment was "fair to poor" and that Plaintiff had limited insight into her condition. (Tr. 665-666).
2. Records Relating to Physical Impairments
In a treatment record dated October 11, 2011, Dr. Triantafyllou noted that Plaintiff had significant difficulty with prolonged standing or walking, and was on chronic pain management. (Tr. 1056). In a residual functional capacity ("RFC") assessment dated November 27, 2011 (Tr. 1032-36), Dr. Triantafyllou reported a poor prognosis with respect to Plaintiff's cervical and lumbar disc disease. (Tr. 1032). Dr. Triantafyllou noted that Plaintiff had a reduced range of motion in her cervical and lumbar spine, an abnormal gait, tenderness, muscle spasms, muscle weakness, and she experienced impaired sleep. (Tr. 1033). Dr. Triantafyllou opined that Plaintiff could stand and/or walk for less than two hours, and sit for about four hours, in an eight-hour workday. (Tr. 1034).
Treating physician, Dr. Sicilia, treated Plaintiff over an extended period for chronic pain syndrome, cervical and lumbar disc degeneration, and severe depression. (Tr. 890-900, 903-04, 918, 1016-19, 1030, 1095). In February 2010, after nearly two years of consistent treatment, Dr. Sicilia was still reporting that Plaintiff had an antalgic gait, mild to moderate reduced range of motion in her cervical spine, severe decrease in range of motion in all directions of her lumbosacral spine, and low back pain upon straight-leg raising. (Tr. 918, 1019). These objective findings, as well as the aforementioned diagnostic impressions, continued throughout the remainder of 2010 and 2011. (Tr. 1016-19, 1030, 1095).
III. Legal Standards and Review of ALJ Decision
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); accord 42 U.S.C. § 1382c(a)(3)(A). A claimant for disability benefits must show that he or she has a physical or mental impairment of such a severity that:
[H]e 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. 20 C.F.R. § 404.1520; accord 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. 20 C.F.R. § 404.1520(a)(4). 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; (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. 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. See Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). 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. Id. The ultimate burden of proving disability within the meaning of the Act lies with the plaintiff. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. § 416.912(a).
When reviewing the Commissioner's decision denying a claim for disability benefits, the Court must uphold the findings of the Commissioner so long as those findings are supported by substantial evidence. Brown v. Bowen, 845 F.2d 1211, 1213 (3d Cir. 1988); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008). 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, 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) (quoting Consolidated Edison Co. v. N.L.R.B., 305 U.S. 197, 229 (1938)). Substantial evidence requires only more than a mere scintilla' of evidence, Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999) (quoting Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995)), 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 ...