United States District Court, M.D. Pennsylvania
MEMORANDUM Docs. 1, 7, 8, 9, 11, 12, 13, 14
GERALD B. COHN, Magistrate Judge.
I. Procedural Background
On April 19, 2011, John Richardson ("Plaintiff") filed an application for Title II Social Security Disability insurance benefits ("DIB"), with a date last insured of September 30, 2013,  and a disability onset date of November 20, 2006. (Administrative Transcript (hereinafter, "Tr."), 25). After the claim was denied at the initial level of administrative review, the ALJ held a hearing on June 12, 2012. (Tr. 40-80). On July 16, 2012, the ALJ found that Plaintiff was not disabled within the meaning of the Act. (Tr. 22-39). On September 14, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 17-21), which the Appeals Council denied on October 11, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-6).
On December 6, 2013, 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 14, 2014, the Commissioner ("Defendant") filed an answer and an administrative transcript of proceedings. (Doc. 7, 8). On April 30, 2014, Plaintiff filed a brief in support of the appeal. (Doc. 9 ("Pl. Brief")). On April 30, 2014, the Court referred this case to the undersigned Magistrate Judge. On May 30, 2014, Defendant filed a brief in response. (Doc. 11 ("Def. Brief")). On June 9, 2014, Plaintiff submitted a reply brief. (Doc. 13 ("Pl. Reply")). Both parties consented to the referral of this case to the undersigned Magistrate Judge, and an order referring the case to the undersigned Magistrate Judge was entered on June 9, 2014. Doc. 12, 14.
II. Relevant Facts in the Record
Plaintiff was born on July 24, 1963, and thus was classified by the regulations as a younger person through the date of the ALJ decision rendered on July 16, 2012. 20 C.F.R. § 404.1563 (c). Plaintiff graduated from high school and completed two years of college. (Tr. 33, 50, 164). Plaintiff alleges disability resulting from work-related injuries in November 2006. Pl. Brief at 2; (Tr. 163). Specifically, Plaintiff alleged back pain due to spinal stenosis, herniated discs, and pinched nerves. (Tr. 163). Plaintiff also reported sleep apnea and carpal tunnel syndrome in both wrists. (Tr. 53, 163). Plaintiff previously applied for DIB and his application was denied following an administrative hearing on September 21, 2009. (Tr. 83-93). The ALJ decision was affirmed and motion for reconsideration was denied on October 25, 2012 in Richardson v. Astrue , No. 4:11-CV-00734 at Doc. 17. Richardson v. Astrue, No. 4:11-CV-00734, 2012 WL 2711263 (M.D. Pa. July 2, 2012).
A. Relevant Treatment History and Medical Opinions
1. Neurology Center: Matt Vegari, M.D.; Slobodan J. Miric, M.D.; Ralf Van Der Sluis, M.D.; and Martha Boulos, M.D.
The doctors from the Neurology Center treated Plaintiff from 2008 to 2010. On September 16, 2009, Dr. Van Der Sluis reported that the CPAP treatment "improved [Plaintiff's] sleep and he feels better during the day.'' (Tr. 305). Dr. Van Der Sluis noted that Plaintiff's pain was "relatively well controlled" with medication and that he was able to perform his average daily activities and look after his young children. (Tr. 305). On December 16, 2009, Dr. Van Der Sluis further noted that the CPAP treatment for sleep apnea was successful, that Plaintiff did not require Percocet on a daily basis to address his alleged pain, and that he was still capable of performing his daily activities and tending to his children without incident. (Tr. 303). Similar observations were reported on March 17, 2010 and, upon physical examination, Dr. Van Der Sluis observed that Plaintiff was "quite comfortable." (Tr. 302).
Plaintiff also visited with Martha Boulos, M.D. (Tr. 244, 246, 269, 396, 469). Dr. Boulos noted spinal stenosis, but observed that Plaintiff possessed full motor strength bilaterally; a steady, normal gait; and the ability to tandem toe and heel walk without issue. (Tr. 244, 246-47, 249). In regard to Plaintiff's diagnosed sleep apnea, Dr. Boulos reported that on May 18, 2009, Plaintiff had used his CPAP machine for approximately two months and responded well to the treatment. (Tr. 244). On July 17, 2009, Dr. Boulos noted that Plaintiff used his narcotic pain medication (Percocet) "very sparingly'' and advised him not to deviate from his current medication regimen. (Tr. 463). She also advised Plaintiff to use soft splints at night to treat his carpal tunnel. (Tr. 463).
Dr. Vegari noted spinal stenosis, select disc disorders, carpal tunnel syndrome and some neck movement limitations, but consistently reported that Plaintiff had: 1) 5/5 (full) motor strength in his arms and legs; 2) normal muscle tone; 3) no muscle atrophy; 4) no drift of outstretched arms; 5) intact sensory modalities and coordination; 6) functional, intact cranial nerves; and 7) an intact gait with normal base and stride. (Tr. 300, 397, 408, 410, 420, 438, 441, 444). From August 2011 through April 2012, Dr. Vegari repeatedly recommended for Plaintiff to receive physical therapy treatment in four-to-six week intervals. (Tr. 259, 397, 408, 411). On April 4, 2011, Dr. Vegari suggested lumbar facet injections but, Plaintiff decided against the treatment. (Tr. 259).
Dr. Vegari directed Plaintiff to wear hand braces at night and when conducting repetitive wrist movements. (Tr. 259, 420). On November 2011, Dr. Vegari administered a Betadine solution injection to Plaintiff's wrists, and Plaintiff reported that this treatment dramatically relieved his alleged pain from a 9/10 level of pain to a 3/10 level of pain. (Tr. 418). Successful results were yielded once again when Dr. Vegari administered this treatment in December 2011. (Tr. 413). In regard to Plaintiff's sleep apnea, Dr. Vegari reported that Plaintiff enjoyed successful results from the CPAP treatment. After reviewing a comprehensive sleep study, Dr. Vegari reported that Plaintiff had a "good response" to CPAP treatment and enjoyed normal sleep latency and efficiency. (Tr. 423). Dr. Vegari directed Plaintiff to continue with the CPAP. (Tr. 423).
With regards to medical opinions, Dr. Vegari gave cursory opinions at the end of treatment notes. (Tr. 411, 445). At the end of a treatment note dated January 18, 2011, Dr. Vegari opined that Plaintiff "remains totally disabled at this time." (Tr. 411). At the end of a treatment note dated March 16, 2012, Dr. Vegari stated "No lifting, pushing or pulling of more than five pounds. [Plaintiff] remains totally disabled." (Tr. 445).
The Court notes that Plaintiff's previous federal court case also summarizes opinion evidence from the ...