United States District Court, M.D. Pennsylvania
MEMORANDUM DOCS. 1, 3, 4, 9, 10
B. COHN, UNITED STATES MAGISTRATE JUDGE
March 20, 2012, Karen L. Hickman ("Plaintiff")
filed as a claimant for disability benefits under Title II of
the Social Security Act, 42 U.S.C. §§ 401-433,
1382-1383 ("Act") and Social Security Regulations,
20 C.F.R. §§ 404 et seq., 416 et seq., with a last
insured date of June 30, 2014,  and claimed a disability onset
date of January 18, 2009. (Administrative Transcript
(hereinafter, "Tr.")» 107-08).
the claim was denied at the initial level of administrative
review, the Administrative Law Judge (ALJ) held a hearing on
September 26, 2013. (Tr. 120-48). On October 30, 2013, the
ALJ found that Plaintiff was not disabled within the meaning
of the Act. (Tr. 120-48). Plaintiff sought review of the
unfavorable decision, which the Appeals Council denied on
February 27, 2015, thereby affirming the decision of the ALJ
as the "final decision" of the Commissioner. (Tr.
April 29, 2015, Plaintiff filed the above-captioned action
pursuant to 42 U.S.C. § 405(g), to appeal a decision of
the Commissioner of the Social Security Administration
("SSA") denying social security benefits. (Doc. 1).
On July 6, 2015, the Commissioner ("Defendant")
filed an answer and an administrative transcript of
proceedings. (Doc. 3, 4). On February 12, 2016, Plaintiff
filed a brief in support of the appeal. (Doc. 9) ("PI.
Brief')). On March 16, 2016, Defendant filed a brief in
response. (Doc. 10 ("Def. Brief')). On November 7,
2016, the Court referred this case to the undersigned
Relevant Facts in the Record
Education, Age, and Vocational History
was born in July 1969 and classified by the Regulations as a
younger individual at the time of the ALJ decision. (Tr.
115); 20 C.F.R. § 404.1563(c). She had a GED and past
work experience as a custodian in a school district and in a
hospital and an order picker. (Tr. 144, 185, 225). Plaintiff
asserts that she is disabled due to due to several
impairments, including chronic neck pain, bulging discs in
neck and back, depression, and reversed cervical lordosis.
(Tr. 224). Earnings reports demonstrate that from earned four
quarters of coverage from 1986 to 2008. (Tr. 214).
Relevant Treatment History and Medical Opinions
Consultative Evaluation: Sara Cornell, Psy.D. 419-26
26, 2012, Dr. Cornell examined Plaintiff and rendered an
opinion regarding Plaintiffs psychological based limitations.
(Tr. 421-26). Dr. Cornell noted that Plaintiff arrived alone
to the examination and was pleasant, and cooperative. (Tr.
424). Dr. Cornell observed that Plaintiff was alert and
oriented to person, place, and time, presented with a
constricted affect and dysphoric mood. (Tr. 424). Dr. Cornell
noted no evidence of a formal thought disorder and that
Plaintiff's thought processes were relevant and
goal-oriented. (Tr. 424). Dr. Cornell noted that Plaintiff
exhibited fair attention and concentration but was easily
distracted. (Tr. 424). Dr. Cornell stated that Plaintiff
appeared to have poor judgment and poor insight into her
difficulties. (Tr. 424).
reported a history of depressive symptoms which started six
years prior and have worsened over time. (Tr. 424). Plaintiff
denied any history of suicidal ideation or intent, denied any
issues with anger, and denied any history of anxiety,
paranoia, or hallucinations. (Tr. 424). Plaintiff reported a
history of experiencing chronic pain in her back due to
herniated and bulging discs. (Tr. 425). Plaintiff reported
experiencing frequent numbness in her right arm, side, and
right foot. (Tr. 425). Plaintiff reported a history of neck
pain due to a work-related injury that occurred about ten
years ago which resulted in herniated and bulging discs in
that area. (Tr. 425). Plaintiff reported participating in
physical therapy, and receiving epidural injections, without
success in eliminating her pain. (Tr. 425). Plaintiff reports
having a prescription of Vicodin (750 mg) and Cymbalta (90
mg). (Tr. 425). Plaintiff reported that she had twice
participated in counseling at ReDCo but discontinued services
there and had also received counseling at NHS. (Tr. 425).
Plaintiff reported experiencing the following symptoms on a
daily basis: sadness, crying, lethargy, anhedonia,
pessimistic thinking, low self-esteem, self-criticism, poor
self-efficacy, feelings of discouragement, guilt, inadequacy,
helplessness, worthlessness, and hopelessness, loneliness,
and isolation from others. (Tr. 425).
reported experiencing mood swings "but these changes in
mood range from 'depressed' to 'very
depressed.'" (Tr. 425). Dr. Cornell noted that
Plaintiff demonstrated short-term memory deficits and
forgetfulness. (Tr. 425). Plaintiff reported being unable to
recall anything from the previous day. (Tr. 425). Plaintiff
reported experiencing poor sleep quality and needing to nap
frequently throughout the day. (Tr. 425). Dr. Cornell
observed that Plaintiffs "gait, posture and general
movements [were] remarkable for pain." (Tr. 425). Dr.
Cornell noted that Plaintiff had fair eye contact and fair
social skills. (Tr. 425). Dr. Cornell noted the Plaintiff had
difficulty providing examples for the likely outcomes of her
behaviors or what she would do in various imaginary
situations. (Tr. 425). Dr. Cornell diagnosed Plaintiff with
Major Depressive Disorder, single episode, severe without
psychotic features and assessed her with a current GAF score
of 40. (Tr. 425-26).
Cornell completed a form indicating that Plaintiff had no
restriction in the ability to interact appropriately with the
public, and had a slight restriction in the ability to
understand, remember and carry out short, simple instructions
and interact appropriately with coworkers and supervisor(s).
(Tr. 421). Dr. Cornell indicated that Plaintiff had a
moderate restriction in the ability to: 1) understand,
remember and carry out short, detailed instructions; 2) make
judgments on simple work-related decisions; 3) respond
appropriately to work pressures in a usual work setting, and;
4) respond appropriately to changes in a routine work
setting. (Tr. 421). Dr. Cornell wrote that Plaintiffs
impairment affects her ability to socialize and her response
it to isolate herself. (Tr. 422). Dr. Cornell opined that
Plaintiff could manage benefits in her own best interest.
James P. Jacques, D.O.
letter to Dr. Jacques dated April 7, 2006, Dr. Joseph Grassi,
M.D. summarized findings from a pain consultation and
assessed Plaintiff with: 1) cervicalgia right upper
extremity, possible C6 or 7 radicular symptomatology; 2)
median neuritis level of the wrist, probable carpal tunnel
syndrome; 3) impingement syndrome right shoulder, and; 4)
myofascitis upper back and neck. (Tr. 413-15). In a physical
therapy discharge report dated June 12, 2007, Plaintiffs
activities of daily living were noted; muscle strength,
cervical range of motion, and shoulder range of motion were
evaluated. (Tr. 416). The physical therapist opined that her
prognosis was good, she met her goals of decreasing pain to 2
out of 10, increasing cervical and shoulder range of motion,
reducing abnormal sensation of radicular symptoms, able to
sit up to one hour at a time, and ability to be independently
complete light housework, heavy housework, meal preparation,
and driving up to sixty minutes. (Tr. 416-18). Plaintiff was
discharged due to non-compliance based on failure to return
after April 25, 2007. (Tr.418).
letter to Dr. Jacques dated February 5, 2009, Dr. Charles
Norelli, M.D., summarized findings from a consultation for
shoulder pain. (Tr. 411-12). Dr. Norelli noted that Plaintiff
was depressed and Cymbalta was tried earlier with "some
improvement." (Tr. 411-12). Examination of the cervical
spine revealed paracervical tenderness upon palpation, active
range of motion of 45 degrees rotation to the left and
passive range of motion of 50 degrees rotation to the left.
(Tr. 411). Dr. Norelli noted that motor strength was normal
throughout and Plaintiff demonstrated diminished reflexes.
(Tr. 411-12). Dr. Norelli opined that Plaintiff had
"primarily a benign myofascial pain disorder, "
that the "C-spine MRI ha[d] very minimal findings,
" Plaintiff had "numerous medications that [were]
not effective and should be withdrawn." (Tr. 412). Dr.
Norelli recommended to stop Fioricet, Flexeril, Zanaflex
(laper), and Relafen and noted that usually he does not
recommend opiates for myofascial pain. (Tr. 412). Dr. Norelli
recommended considering Sertraline as a replacement for
Cymbalta and that trying massage to address pain was
reasonable to consider. (Tr. 412).
2012, Dr. Jacques completed an assessment of Plaintiffs
physical limitations. (Tr. 401-05). Dr. Jacques wrote that he
had seen Plaintiff from January 30, 2004, to April 26, 2012.
(Tr. 401). Plaintiff was diagnosed with depression in 2004
and cervical radiculopathy in 2006. (Tr. 401). Dr. Jacques
wrote that Plaintiff had cervical pain with radiation to
right arm for ten years in addition to severe depression
without suicidal ideation. (Tr. 401). Plaintiff had been
treated with Vicodin and physical therapy, that sitting and
standing exacerbates the pain while ice and Vicodin
alleviates the pain. (Tr. 401). Dr. Jacques indicated that
there was paravertebral muscle spasm in the T1-T3 for ten
years. (Tr. 401). Dr. Jacques indicated that Plaintiff had
negative straight leg raising tests, her sensation was intact
to light touch, her motor strength was normal, and she had no
atrophy. (Tr. 401-02). Dr. Jacques noted that Plaintiff
demonstrated full range of motion in the dorso-lumbar
regions, upper extremities, and lower extremities. (Tr. 402,
406-07). Dr. Jacques indicated that Plaintiff had the
following diminished range of motion in the cervical regions:
1) 15 degrees forward flexion (out of a possible 30 degrees);
2) 15 degrees backward extension (out of a possible 30
degrees); 3) 15 degrees neck rotation (out of a possible 45
degrees); 4) 10 degrees left lateral flexion (out of a
possible 40 degrees), and; 5) 5 degrees right lateral flexion
(out of a possible 40 degrees). (Tr. 402). However, in
another form, he indicated that Plaintiff demonstrated 5
degrees of left and right lateral flexion, flexion,
extension, as well and left and right rotation. (Tr. 407).
Dr. Jacques noted that Plaintiff did not use any assistive
device for ambulation, that her gait was normal, and wrote
"normal" to describe her ability to: 1) get on and
off the examining table; 2) walk on heels and toes; 3) squat;
4) arise from a squatting position, and; 5) arise from a
chair. (Tr. 403). Dr. Jacques noted that Plaintiff has not
had surgery performed. (Tr. 403). Dr. Jacques completed a
check-mark opinion indicating that Plaintiff could: 1)
occasionally lift and carry up to 100 pounds; 2) stand and
walk a total of 1 hour or less in an 8-hour day; 3) sit two
hours a day; and, 4) never bend, kneel, crouch, stoop,
balance, or climb. (Tr. 403-05). Dr. Jacques noted that
Plaintiff had a severe limitation in the ability to use upper
and lower extremities and checked boxes indicated that
Plaintiffs impairment affected her reaching, handling,
fingering, feeling, seeing, hearing, speaking, tasting,
smelling, and continence. (Tr. 404-05). With regard to
environmental limitations, Dr. Jacques noted that humidity
affected the degree of pain that Plaintiff experienced. (Tr.
405). Dr. Jacques did not respond to the form questions
requesting explanation in support of his medical findings.
(Tr. 404-05). Dr. Jacques concluded the form writing that
Plaintiff was still very depressed and getting psychotherapy.
Psychiatric Review Technique: James Vizza, Psy.D.
24, 2012, Dr. Vizza reviewed the medical record and rendered
an opinion regarding Plaintiff's psychological based work
impairments. (Tr. 179-85). Dr. Vizza opined that Plaintiff
had: 1) a moderate restriction of activities of daily living;
2) mild difficulties in maintaining social functioning; 3)
moderate difficulties in maintaining concentration,
persistence or pace, and; 4) no repeated episodes of
decompensation, each of extended duration. (Tr. 179). Dr.
Vizza opined that Plaintiff was not significantly limited in
her ability to: 1) remember locations and work-like
procedures; 2) remember and carry out very short and simple
instructions; 3) perform activities within a schedule,
maintain regular attendance, and be punctual within customary
tolerances; 4) sustain an ordinary routine without special
supervision; 5) work in coordination with or in proximity to
others without being distracted by them; 6) complete a normal
workday and workweek without interruptions from
psychologically based symptoms and to perform at a consistent
pace without an unreasonable number and length of rest
periods; 7) be aware of normal hazards and take appropriate
precautions; 8) travel in unfamiliar places or use public
transportation; and, 9) set realistic goals or make plans
independently of others. (Tr. 183-84).
Vizza opined that Plaintiff was moderately limited in her
ability to: 1) understand and remember and carry out detailed
instructions; 2) maintain attention and concentration for
extended periods; 3) make simple work-related decisions; and,
4) respond appropriately to changes in the work setting. (Tr.
183-84). Dr. Vizza explained that Plaintiff was able to carry
out very short and simple instructions, maintain regular
attendance and be punctual, and could complete a normal
workday without exacerbation of psychological symptoms. (Tr.
183). Dr. Vizza opined that Plaintiff had no restrictions
regarding ability to interact socially. (Tr. 184). Dr. Vizza
found that Dr. Jacques' May 2012 opinion was not
supported by the evidence in the record, which rendered the
opinion less persuasive. (Tr. 184-85). Dr. Vizza found the
July 2012 opinion from Dr. Cornell to be consistent with his
opinion regarding Plaintiffs psychiatrically based
limitations. (Tr. 184), Dr. Vizza concluded that the
limitations resulting from psychological impairments do not
preclude Plaintiff from performing the basic mental demands
of competitive work on a sustained basis. (Tr. 184).
Non-Examining Opinion: Elizabeth Kamenar, M.D.
18, 2012, Dr. Kamenar reviewed Plaintiffs medical records and
rendered an opinion regarding Plaintiffs physical
limitations. (Tr. 180-87). Dr. Kamenar noted that Plaintiff
could prepare some meals, vacuum, drive, shop, use a
computer, lift five to ten pounds, walk twenty to thirty
yards and did not use an ambulatory assistive device. (Tr.
180). Dr. Kamenar noted that Plaintiff wrote out detailed
ADLs. (Tr. 180). Dr. Kamenar opined that Plaintiff could
never climb ladders and could: 1) occasionally lift and/or
carry twenty pounds and frequently lift and/or carry ten
pounds; 2) stand and/or walk six hours in an eight-hour day;
3) sit six hours in an eight-hour day, and; 4)occasionally
climb ramps/stars, balance, stoop, kneel, crouch, and crawl.
(Tr. 181). Dr. Kamenar opined that Plaintiff had no
limitations in pushing or pulling and no manipulative
limitations. (Tr. 181). In support of her opinion Dr. Kamenar
cited to Plaintiffs diagnosis of cervical degenerative disc
disease, a January 2009 MRI, a February 2009 EMG, and an
April 2012 examination where it was noted that Plaintiff had
cervical radiculopathy with spasm, negative bilateral
straight leg raise (SLR), intact sensation, 5/5 motor
strength, equal deep tendon reflexes ("DTRs"), no
atrophy; lumbar flexion at 90 degrees, cervical flexion at 5
to 15 degrees, and normal range of motion in bilateral upper
and lower extremities. (Tr. 182). Dr. Kamenar also noted that
during the April 2012 examination, Plaintiff used no
assistive device, presented with normal gait, was able to
normal get on/off the examination table, able to rise from
the chair, and demonstrated normal walking on heels and toes,
normal squatting. (Tr. 182). Dr. Kamenar opined that
Plaintiff would be unable to perform past relevant work
because Plaintiff was limited to light exertional work that
was also simple and routine. (Tr. 186).
Radiographic Records: Fuhai Li, M.D.; John Fiss, M.D.;
Richard P. Kennedy, M.D.
April 10, 2007, Dr. Li interpreted images of Plaintiff's
cervical spine and concluded that they revealed: 1) cervical
degenerative changes with disk desiccation; 2) mild disk
bulge at the level of C3-4, C4-5 and C5-6 with mild
impingement of thecal sac; 3) no spinal canal stenosis; 4)
minimal narrowing of the neural foramina at the level of
C3-4, C4-5 and C5-6 bilaterally; 5) no evidence of spinal
cord lesion or spinal cord compression. (Tr. 301). On January
19, 2009, Dr.
interpreted images of Plaintiffs cervical spine and concluded
that they revealed mild degenerative changes resulting in
mild right neural foraminal narrowing at ¶ 3-C4 and mild
central canal narrowing at ¶ 5-C6. (Tr. 316). On August
7, 2013, Dr. Kennedy interpreted images of Plaintiffs lumbar
spine and concluded that they were unremarkable. (Tr. 470).
Lehigh Valley Hospital-Cedar Crest: Matthew A. Nussbaum,
D.O.; Yuebing Li, M.D.; Bruce Nicholson, M.D.
January 19, 2009, to January 21, 2009, Plaintiff sought
treatment following receipt of an epidural steroid injection
from her pain management doctor. (Tr. 303). Plaintiff
reported developing a severe headache which was thought to be
a spinal headache. (Tr. 303). Dr. Nussbaum summarized that
MRI showed minimal herniated disks for mild degenerative
joint disease. Surgery felt that there was no surgical
intervention that would likely help her with her pain at this
time. Pain Management felt that a blood patch was not
indicated in the cervical region for pain at this time.
Neurology agreed that this was not migraine, but likely
related to CSF leak from her prior cervical injection.
(Tr. 303). In an MRI form dated January 19, 2009, it was
noted that Plaintiff was ambulatory with minimal assistance,
and able to remember instructions for up to fifteen minutes.
(Tr. 315). During a consultation dated January 19, 2009, Dr.
Nicholson observed that Plaintiff demonstrated a "full
range of motion in the joints, upper and lower extremities
without restriction" and that her strength was intact.
(Tr. 327). During consultations dated January 20, 2009,
Plaintiff reported a history of chronic neck pain for years
with on month of right arm pain. (Tr. 320).
attending physician noted that Plaintiff was in discomfort
when sitting up. (Tr. 320, 323). Plaintiff reported that On
January 15, 2009, she had another epidural injection in the
lower cervical area, developed a mild headache on the same
day, but she went to work that day and the day after. (Tr.
323). Dr. Li observed that Plaintiff was alert and oriented
to time, place, and person, followed all commands, had no
language deficit, ...