United States District Court, W.D. Pennsylvania
MEMORANDUM OPINION AND ORDER OF COURT
TERRENCE F. MCVERRY, Senior District Judge.
Laura Pearl Woodsbey ("Plaintiff") brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), for judicial review of the final decision of the Commissioner of Social Security ("Commissioner"), which denied her application for supplemental security income ("SSI") under Title XVI of the Social Security Act ("Act"), 42 U.S.C. §1381-1383(f). Pending before the Court are the parties' cross-motions for summary judgment (ECF Nos. 8, 10), which have been fully briefed, and are ripe for disposition. For the reasons that follow, Plaintiff's motion will be DENIED, and the Commissioner's motion will be GRANTED.
A. Factual Background
Plaintiff was born on December 26, 1969, and was forty-one years old when she filed her current application for social security benefits. (R. 29). Plaintiff did not complete the ninth grade, and has a "dysfunctional" family background. (R. 56). At the time of the hearing, Plaintiff lived with her sister-in law. (R. 52). Plaintiff has also been incarcerated nine times for various charges and has spent approximately eight years of her life in prison. (R. 607). Her most recent incarceration lasted twelve months and concluded in September 2011. (R. 53). The Administrative Law Judge ("ALJ") noted in his opinion that Plaintiff had received SSI in the past, but her eligibility for benefits was terminated as a result of her incarceration. (R. 15).
B. Relevant Educational, Medical, and Opinion Evidence
A psychological study of Plaintiff's cognitive function conducted in 1978, while Plaintiff was in the first grade, indicated that she displayed "mild mental retardation and inability to function in normal developmental curriculum." (R. 213). Plaintiff's IQ was 66. Id.
Treatment notes from Stairways Behavior Health, where Plaintiff underwent treatment for her mental impairments from May 2008 to November 2009, albeit inconsistently, showed that Plaintiff experienced mood swings and anxiety of fluctuating intensity. ( See e.g., R. 225, 231, 235). Gail Holland, D.O., a physician at Stairways, assigned Plaintiff a GAF Score of 45-50 in May 2008. (R. 257).
A psychological evaluation conducted by Byron Hillin, Ph.D., in April 2009 reflected that Plaintiff's full scale IQ was 72, demonstrating borderline intellectual functioning. (R. 263). Dr. Hillin noted that Plaintiff's Weschler Adult Intelligence Scale-III results indicated that she has below average intelligence in the areas of reasoning, math, spelling, and reading comprehension. Id. She was also classified as being "marginally literate." (R. 265). Dr. Hillin also found that Plaintiff's ability to maintain full-time employment was "very precarious, " and he recommended that Plaintiff be limited to food service, cleaning or other "hands-on" work. Id.
Medical records from the Bureau of Prisons, generated from November 2010, to May 2011, during Plaintiff's term of incarceration, demonstrated that Plaintiff was generally "pleasant and cooperative." (R. 283). A physical and mental status examination conducted by Tiffany Sanders, M.D., in November 2010 indicated that Plaintiff had asthma, benign essential hypertension, psychosocial and environmental problems, but that she otherwise had normal mood and affect. (R. 318). Plaintiff's healthcare providers from the Bureau of Prisons evaluated her and assigned her a GAF score range from 51 to 70 on numerous occasions, (R. 274, 278, 294, 306, 318, 347), but on two occasions, she received a specific GAF score of 55. (R. 294, 347).
Cameron McGavin, M.D., evaluated Plaintiff for mental health issues from June to September, 2011, while she resided at Renewal, a half-way house. (R. 498, 525). Plaintiff reported that she was depressed and anxious, although Dr. McGavin suspected possible "malingering" and symptom magnification. (R. 520). During this period, Plaintiff also got a full time job at McDonald's, although she claimed the job increased the level of her anxiety and stress. (R. 504, 509). As a result, Dr. McGavin recommended that Plaintiff be excused from work for sixty days to address these issues. (R. 503). In September, 2011, Dr. McGavin assessed Plaintiff's GAF score at 40-45. (R. 502).
On November 18, 2011 Rebecca Billings, Ph.D., conducted a mental residual functional capacity ("MRFC") assessment and consultative psychological evaluation of Plaintiff. Dr. Billings opined that Plaintiff had slight limitations in her ability to interact appropriately with the public, her supervisors, and her co-workers, while she had marked limitations in her ability to respond appropriately to work pressures in a usual work setting, and moderate limitations in her ability to respond appropriately to changes in a routine work setting. (R. 612). Moreover, Dr. Billings diagnosed Plaintiff with Bipolar II disorder, major depressive disorder, cocaine and alcohol dependence in full remission, personality disorder (not otherwise specified), and borderline intellectual functioning. (R. 611). Dr. Billings assigned Plaintiff a GAF score of 50 and noted a full scale IQ of 72. (R. 609, 611).
In December 2011, Manuella Link, Ph.D., a state agency psychological consultant, completed an MRFC assessment after review of Plaintiff's medical records. (R. 85). Dr. Link found that Plaintiff had the ability to meet the basic mental demands of sustained work. (R. 91). That same month, James Caramanna, M.D., performed a physical residual functional capacity assessment, in which he found that Plaintiff was capable of performing medium exertional work. (R. 88-89).
Plaintiff returned to Stairways Behavioral Health for psychological evaluations and check-ups from January 2012 to March 2013. (R. 644, 645). While there, Sean Su, M.D., and his colleagues treated Plaintiff for mood swings and anxiety, along with racing thoughts. In February 2013, Dr. Su assigned Plaintiff a GAF score of 50. (R. 651). He also assessed Plaintiff as "awake and alert, " while her intelligence appeared around average, her memory was intact, and her affect was blunted. Id. Plaintiff described her mood as "up and down." Id.
On May 12, 2013, Dr. Su completed a medical source statement, in which he evaluated Plaintiff's mental impairments. (R. 661). Dr. Su opined that Plaintiff had extreme limitations in her ability to make judgments on simple, work-related decisions, moderate limitations in her ability to understand, remember, and carry out detailed instructions, and slight limitations in her ability to understand, remember, and carry out short, simple instructions. Id. Dr. Su also opined that Plaintiff had extreme limitations in her ability to interact appropriately with the public, supervisors, and co-workers, and had similarly extreme limitations in her ability to respond to work pressures in a usual work setting. (R. 662). Dr. Su found that Plaintiff would likely call off from work five out of five days in the work week, and would need more than nine breaks during the workday. (R. 663). Dr. Su based these findings solely on Plaintiff's "extremely unstable mood." Id.
C. Procedural History and Opinion of the Administrative Law Judge
Plaintiff applied for SSI on September 7, 2011, alleging disability since October 1, 2005, and claiming that she suffered from major depression, schizophrenia, post-traumatic stress disorder, and heart disease. (R. 81, 161). The agency denied Plaintiff's application. (R. 80). She thereafter requested an administrative hearing, which was held on June 6, 2013. (R. 104). An ALJ heard testimony from Plaintiff and a vocational expert. (R. 45). Plaintiff's counsel had the opportunity to question the vocational expert at the hearing. (R. 76).
The ALJ subsequently issued his opinion, explaining his decision to deny Plaintiff's application for social security benefits. At Step One the ALJ found that Plaintiff had not engaged in substantial gainful activity since her application date. (R. 17). At Step Two of the analysis, the ALJ concluded that Plaintiff had the following severe impairments:
gastroesophageal reflux disease (GERD), obesity, cervical degenerative disc disease, lumbar disc bulge and spondylosis, thoracic spondylosis, migraine headaches, asthma/chronic obstructive pulmonary disease (COPD), bipolar disorder, attention deficit hyperactivity disorder (ADHD), major depressive disorder, generalized anxiety disorder, borderline intellectual functioning, learning disorder, and a personality disorder.
Id. In so concluding, the ALJ also discounted some of Plaintiff's alleged impairments, including schizophrenia, PTSD, and any medically determinable cardiac disorder because these impairments were not established in any records or medical documentation. (R. 18).
At Step Three of the analysis, the ALJ concluded that none of Plaintiff's impairments met or exceeded one of the listed impairments in 20 C.F.R. Part 404, Subpt P, Appendix 1. Id. The ALJ referenced Plaintiff's MRFC assessment conducted by Dr. Rebecca Billings in 2011, and the psychological evaluation conducted by Dr. Byron Hillin, in 2009, marked as Exhibits 1F and 3F, respectively, in his analysis. (R. 21).
At Step Four, "after considering the entire record, " the ALJ concluded that Plaintiff was limited to the following ...