United States District Court, M.D. Pennsylvania
REPORT AND RECOMMENDATION TO DENY PLAINTIFF'S APPEAL Docs. 1, 13, 14, 16, 17
GERALD B. COHN, Magistrate Judge.
REPORT AND RECOMMENDATION
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying the application of Plaintiff Jodie Lynn Aldrich for disability insurance benefits ("DIB") under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). In order to receive DIB, Plaintiff has to establish disability prior to March 31, 2010, her date last insured. A state agency physician reviewed Plaintiff's records, and concluded that she could engage in a range of work as of March 31, 2010. The administrative law judge ("ALJ") relied on this opinion and concluded that Plaintiff was not disabled as of March 31, 2010. Plaintiff asserts that the Court should reweigh the medical evidence that was reviewed by the state agency physician and find that it supports an award of benefits. However, the ALJ was entitled to rely on the state agency physician's interpretation of these records. Plaintiff also asserts that the ALJ should have credited her complaints of pain prior to March 31, 2010 because the medical evidence corroborates those complaints. Again, however, a medical expert reviewed the medical evidence and concluded that, while Plaintiff experienced limitations as a result of pain, she was not precluded from working. Moreover, Plaintiff has not challenged the other reasons provided by the ALJ for discounting the credibility of subjective complaints, namely Plaintiff's lack of treatment from 2006 to 2008, with only conservative treatment thereafter, and Plaintiff's testimony that her condition worsened after having surgery in October of 2011. For the foregoing reasons, the Court recommends that Plaintiff's appeal be denied, the decision of the Commissioner be affirmed, and the case closed.
II. Procedural Background
On February 3, 2011, Plaintiff filed an application for DIB. (Tr. 109-110). On April 20, 2011, the Bureau of Disability Determination denied this application (Tr. 89-93), and Plaintiff filed a request for a hearing on May 16, 2011. (Tr. 94-95). On January 30, 2012, an ALJ held a hearing at which Plaintiff-who was represented by an attorney-and a vocational expert appeared and testified. (Tr. 53-86). On February 14, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 10-26). On March 30, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 6-9), which the Appeals Council denied on July 2, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-5).
On September 12, 2013, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On May 28, 2014, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 13, 14). On April 29, 2014, the case was referred to the undersigned Magistrate Judge. On July 14, 2014, Plaintiff filed a brief in support of her appeal ("Pl. Brief"). (Doc. 16). On August 14, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 17). The matter is now ripe for review.
III. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Brown v. Bowen, 845 F.2d 1211, 1213 (3d Cir. 1988). 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, 565 (1988) (quoting Consol. Edison Co. of New York v. N.L.R.B., 305 U.S. 197, 229 (1938)). In other words, substantial evidence requires "more than a mere scintilla" but is "less than a preponderance." Jesurum v. Sec'y of U.S. Dep't of Health & Human Servs., 48 F.3d 114, 117 (3d Cir. 1995) (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)).
IV. Sequential Evaluation Process
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); 42 U.S.C. § 1382c(a)(3)(A). The Act requires that a claimant for disability benefits 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).
The Commissioner uses a five-step evaluation process to determine if a person is eligible for disability benefits. See 20 C.F.R. § 404.1520; see also Plummer v. Apfel, 186 F.3d 422, 428 (3d Cir. 1999). If the Commissioner finds that a Plaintiff is disabled or not disabled at any point in the sequence, review does not proceed. See 20 C.F.R. § 404.1520. 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 from 20 C.F.R. Part 404, Subpart P, Appendix 1 ("Listing"); (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. See 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. 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. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). The ultimate burden of proving disability within the meaning of the Act lies with the claimant. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. § 416.912(a).
V. Relevant Facts in the Record
Plaintiff was born on June 16, 1974, and was classified by the regulations as a younger individual through the date last insured. (Tr. 21). 20 C.F.R. § 404.1563. Plaintiff has at least a high school education and has past relevant work as a "CNC operator, sign maker, general laborer, freezer stacker, and day care worker." (Tr. 21). Plaintiff must establish disability prior to March 31, 2010, her date last insured, to be entitled to DIB, so the Court focuses on the evidence relevant to this date. (Tr. 15).
In July of 2004, Plaintiff fell and injured her tailbone. (Tr. 229). X-rays of her coccyx were negative, but she began reporting an increase in lower back pain radiating into her thigh a few weeks later. (Tr. 232). She continued complaining of low back pain through September of 2004. (Tr. 233-35). In October of 2004, Plaintiff reported injuring her wrist at work. (Tr. 236). Plaintiff continued complaining of low back pain in February of 2005, and reported injuring her tailbone again after falling off a ladder in April of 2005. (Tr. 240, 242). Plaintiff was prescribed Vicodin, "no more than 8 a day." (Tr. 243).
In December of 2005, Plaintiff complained of shoulder and rotator cuff pain from repetitive movements at work. (Tr. 254). Plaintiff was prescribed physical therapy and placed on work restrictions for fourteen days. (Tr. 254).
On March 21, 2008, Dr. Vikas Passi, M.D., evaluated Plaintiff as a new patient. (Tr. 298). Plaintiff was "[f]eeling well" and she was "exercising twice a week." (Tr. 298). Plaintiff reported that she had "a multitude of problems, " including a "fusion between the tail bone and the spine." (Tr. 298). Plaintiff was taking 1.0 m.g. of Lorazepam twice a day and "Hydrocodone/Apap 10-325 mg" every four to six hours as needed. (Tr. 299). Plaintiff reported that she had "been taking the pain medication every 4-6 hrs and has been doing so for about five years...the patient's bottle [had] 250 pills dispensed and this was to be a months supply." (Tr. 298). Plaintiff denied musculoskeletal, neurologic, and psychiatric symptoms. (Tr. 298). Plaintiff "appear[ed] healthy and well developed, " she "walk[ed] with a normal gait, " she had full range of motion, and her sensation and reflexes were intact. (Tr. 299). Plaintiff was assessed to have chronic pain syndrome, and her records were requested from her former doctor. (Tr. 299). Notes indicate "[u]nable to have new MRI done because she has no insurance." (Tr. 299).
At a follow-up with Dr. Passi on April 28, 2008, notes indicate:
[Plaintiff] follows up for chronic lumbago. I spoke to her former physician, who confirmed the diagnosis and felt that the lumbago was the organic basis for continued pain medication based on imaging studies that he had done in the past and her history. She apparently had a history of low back injury and may have had some history of coccyx fracture as well. He was not able to confirm MRI findings for me, but formal records are still pending. He did tell me that the patient had been on a chronic stable dose of the hydrocodone for nearly a year and a half without any evidence of abuse, etc.
(Tr. 302). Plaintiff had tenderness to palpation in her back, but her physical examination was otherwise normal. (Tr. 302). Plaintiff submitted to a urine drug screen and her medications were continued. (Tr. 302).
On October 20, 2008, Plaintiff followed-up with Dr. Passi. (Tr. 305). Dr. Passi noted that Plaintiff's back pain was "controlled." (Tr. 305). Dr. Passi also noted that Plaintiff would "hopefully have insurance in the next few months as she has started a new job. We can then start referring her to pain management and get the appropriate imaging studies to better manage her condition." (Tr. 305). Plaintiff's physical examination was normal. (Tr. 305).
On January 27, 2009, Dr. Passi noted that Plaintiff "now has insurance, " so they were "to begin the diagnostic work...to try to establish diagnosis as well as further treatment." (Tr. 314). Plaintiff was complaining of back pain and pain in her knees, so diagnostic imaging was done of the back and knees. (Tr. 314). X-rays of Plaintiff's lumbar spine and knees were "unremarkable." (Tr. 315, 317). On March 2, 2009, Plaintiff had a "normal physical exam" with a normal gait and "intact strength and sensation" in her extremities. (Tr. 317). Plaintiff's medications were continued. (Tr. 317).
On May 26, 2009, Plaintiff followed-up with Dr. Passi. (Tr. 322). Plaintiff was reporting a lump on the back of her neck that had been present for about a year that was getting bigger and more painful. (Tr. 322). She reported that "some mornings it is very painful and radiates down back pain & shoulders" and that she sometimes has numbness and tingling in her fingers. (Tr. 322). On examination, her head and neck were grossly within normal limits, with no tenderness and full range of motion with discomfort. (Tr. 322). X-rays of Plaintiff's cervical spine from that day indicated "a negligible levoconvex curvature of the lower cervical spine, " "at least mild degenerative disc disease at C5-6 and to a lesser extent at C4-5, " "uncovertebral degenerative spurring, " and "at least moderate" foraminal stenosis. (Tr. 324). Plaintiff's Prilosec, Lorazapam, hydrocodone, and nabumetone were continued, and she was also prescribed a Medrol Dosepak and cyclobenzaprine. (Tr. 323). At a follow-up on June 7, 2009, Dr. Passi reviewed Plaintiff's X-rays and ordered an MRI of her cervical spine "due to radicular symptoms." (Tr. ...