United States District Court, M.D. Pennsylvania
John E. Jones III
above-captioned action is one seeking review of a decision of
the Acting Commissioner of Social Security
(“Commissioner”),  denying Plaintiff Eugene
Motes' application for Social Security Disability
Insurance Benefits (“DIB”), pursuant to 42 U.S.C.
insurance benefits are paid to an individual if that
individual is disabled and “insured, ” that is,
the individual has worked long enough and paid social
security taxes. Motes met the insured status requirements of
the Social Security Act through December 31, 2013. (Tr.
filed his application for DIB under Title II of the Social
Security Act (“Act”), on October 10, 2012,
alleging disability beginning April 8, 2012. (Tr. 13). Motes
had been diagnosed with several impairments, including left
shoulder pain, sleep apnea, diabetes mellitus, obesity, ADHD,
schizophrenia, bipolar disorder, depression, and anxiety.
(Tr. 15). On June 13, 2013, Motes' application was
initially denied by the Bureau of Disability Determination.
(Tr. 13 and 78).
hearing before the Administrative Law Judge
(“ALJ”) Office of Disability and Adjudication and
Review of the Social Security Administration was conducted on
November 6, 2014. (Tr. 31-77). At the hearing, Motes was
represented by counsel, and a Vocational Expert testified.
(Id.). On January 30, 2015, the ALJ issued a
decision denying Motes' application. (Tr. 13-25). On May
17, 2016, the Appeals Council declined to grant review. (Tr.
1-6). Thus, the ALJ's decision stood as the final
decision of the Commissioner.
filed a complaint before this Court on June 24, 2016. (Doc.
1). Motes also filed an application to proceed in forma
pauperis (Doc. 2), which the Court granted. (Doc. 3). After
supporting and opposing briefs were submitted (Docs. 10, 12,
13), the appeal became ripe for disposition.
appeals the ALJ's determination on four grounds: (1)
substantial evidence does not support the ALJ's step
three evaluation; (2) substantial evidence does not support
the ALJ's RFC assessment; (3) the ALJ failed to properly
weigh the opinion evidence; and (4) the ALJ improperly
discounted Motes' credibility. For the reasons set forth
below, the decision of the Commissioner will be affirmed.
was forty-four years of age on the date last insured; has a
high school education and is able to communicate in English;
and has past relevant work experience as a warehouse laborer.
(Tr. 23, 24).
late hours of February 24, 2012, Motes presented to the Holy
Spirit Hospital Behavioral Health Center with complaints of
anxiety due to nightmares and visions of past childhood
abuse, including physical abuse by his parents. (Tr. 281). He
described having nightmares of killing his family and
thoughts of walking in front of the train. (Id.).
Motes also complained of declined sleep and appetite, weight
loss, negative self-talk and thoughts. (Id.). It was
noted that Motes had stopped taking his prescribed Prozac and
Concerta. (Id.). Motes was discharged on February
25, 2012 with a diagnosis of depression, suicidal ideation,
hyperglycemia, and uncontrolled diabetes mellitus. (Tr. 285).
April 3, 2012, Motes underwent a psychiatric evaluation with
Sylvestre De La Cruz, M.D. (Tr. 339). Motes related to Dr. De
La Cruz that he has been feeling depressed in mood associated
with anhedonia, insomnia, and a decrease in appetite. (Tr.
339). On mental examination, Dr. De La Cruz found Motes'
concentration to be fairly good, he had good attention and
focus, denied any suicidal or homicidal thoughts, and also
denied any delusions or hallucinations of any type. (Tr.
341). Dr. De La Cruz did not see any conclusive evidence of
ADHD but noted that Motes has a history of having been
physically and emotionally abused by both of his parents and
from that, is experiencing nightmares and flashbacks of the
abuse. (Id.). Motes was diagnosed with bipolar
disorder and PTSD. (Id.). Motes stated that he
preferred Depakote and Prozac, which he was prescribed, and
was referred for individual counseling for PTSD. (Tr. 342).
April 16, 2012, Motes presented to Pinnacle Health's
Kline Health Center for evaluation of his diabetes. (Tr.
304). V. Gorrepati, MD, noted that Motes is 5'9"
tall, weighed 220.6 pounds and had a BMI of 32.11. (Tr. 305).
Dr. Gorrepati's assessment/plan notes diabetes mellitus,
type 2; obstructive sleep apnea, stable; narcolepsy, no signs
since nine years and not on medication; bipolar 1 disorder,
stable and on medication; and depression, stable and on
medication. (Tr. 306).
returned to the Kline Health Center on September 17, 2012 for
a follow-up of his diabetes. (Tr. 301). Motes stated that he
had run out of Novalog and his blood glucose was in the low
300s. (Id.). On psychiatric evaluation, his symptoms
included anxiety, depression, and insomnia. (Tr. 302). Motes
was given samples of Lantus and Humalog and an appointment
was set up with a social worker about assistance with
medications. (Tr. 303).
December 10, 2012, Motes presented to the Pinnacle Health
emergency room with complaints of high blood sugar, stating
that he was out of Novalog for the past three weeks. (Tr.
349). Motes was diagnosed with hyperglycemia, uncontrolled
diabetes, and medication noncompliance. (Tr. 354). He was
further advised to stay on his insulin. (Id.).
March 26, 2013, Christine Daecher, D.O., performed a
consultative examination. (Tr. 405-12). Dr. Daecher noted
Motes' weight was 226 pounds and that he had a BMI of
34.16. (Tr. 409). Dr. Daecher further observed that sensation
diminished in Motes's early left foot, had some degree of
diabetic neuropothy in his feet, and that he exhibited
anxious mood and blunted affect. (Tr. 411). With regard to
his complaints of left shoulder pain, Dr. Daecher noted pain
with flexion and abduction, only occurring with shoulder
shrugging type movements or shoulder rolling. (Tr. 408, 410).
Dr. Daecher diagnosed diabetes mellitus type II,
uncontrolled; joint pain (shoulder), and generalized anxiety
(although, Dr. Daecher notes that she did not fully evaluate
Motes for his mental health conditions). (Tr. 411-12).
28, 2013, Stanley E. Schneider, Ed.D., performed a
psychological consultative examination. (Tr. 419). During
examination, Dr. Schneider observed Motes as being highly
anxious, nervous, and apprehensive. (Tr. 421). Dr. Schneider
notes his mood reflects both anxiety and underlying
depression; his affect was anxious; and that he is
agoraphobic. (Tr. 425). Motes reported to Dr. Schneider that
he experiences both auditory and visual hallucinations, and
admitted to recurrent suicidal ideation, but denied any plan
or intent, and any homicidal thinking. (Id.). Dr.
Schneider also noted that Motes has memory deficits on a
short-term nature, and that his attention and concentration
are significantly impaired. (Id.). Dr. Schneider
diagnosed posttraumatic stress disorder, panic disorder with
agoraphobia, bipolar disorder, and ADHD. (Tr. 426).
11, 2013, Louis Poloni, Ph.D., a state agency psychologist,
reviewed Motes' claim for benefits and opined that,
despite a moderate restriction in activities of daily living,
maintaining social functioning, and concentration,
persistence, or pace, Motes had the mental residual
functional capacity to perform simple, unskilled work in an
isolated setting. (Tr. 85, 90). Motes presented again to the
Pinnacle Health emergency room on September 1, 2013. (Tr.
445). His complaints included high glucose, headaches, arm
and leg tingling, and increased thirst and urination. (Tr.
445, 447). He stated that he did not have test strips for
three months. (Tr. 445). Motes was diagnosed with dehydration
and mild hyperglycemia. (Id.). Psychiatric
examination revealed normal affect, judgment and insight,
normal memory, and normal concentration. (Tr. 447). Discharge
instructions provide that Motes continue to do the great job
in keeping his glucose controlled in spite of not having test
strips, and stay well hydrated. (Tr. 451).
follow up from his emergency room visit, Motes presented to
Pinnacle Health's Kline Health Center on September 3,
2013, where he was seen by Allyson Miller, a nurse
practitioner. (Tr. 487). Ms. Miller's notes indicate that
Motes was looking to obtain glucose strips and that he is not
currently taking insulin due to not having insulin strips.
(Id.). Motes denied any complaints other than
feeling tired more than normal. (Id.). On
evaluation, Motes' mood and affect were appropriate and
he was oriented to time, place, person, and situation. (Tr.
489). Ms. Miller's assessment/plan included diabetes type
2 with renal changes, uncontrolled; microproteinuria;
diabetes type 2 with neurologic changes, refer to podiatry in
regards to tingling in feet; unspecified type schizophrenia;
and hypertension. (Tr. 489).
later, on September 11, 2013, Motes had a follow-up
appointment with Ms. Miller. (Tr. 484). Motes stated he was
feeling much better, and about to do more exercise and has
less fatigue. (Tr. 484). Motes continued treatment with Ms.
Miller through April 10, 2014. (Tr. 465). Ms. Miller's
December 9, 2013 notes indicate that Motes' physical
therapy for his shoulder is going fantastic, his psych issues
are stable with no recent changes in his medications, and her
assessment/plan included diabetes mellitus type II
uncontrolled; left shoulder pain; sleep apnea; bipolar 1
disorder; and schizophrenia. (Tr. 455, 458). Ms. Miller's
March 3, 2014 notes indicate that Motes received podiatry
shoes and that his BiPap machine was working and Motes sleeps
with no apnea. (Tr. 460). On physical examination, he had a
normal range of motion, muscle strength, and stability in all
extremities with no pain on inspection. (Tr. 463). On April
10, 2014, Motes saw Ms. Miller for his one month follow up
for his diabetes. (Tr. 465). Ms. Miller notes that Motes is
working out, weight lifting, eating much better, and that he
reports that his clothes are fitting better. (Id.).
Residual Functional Capacity Assessments
March 26, 2013, Dr. Daecher, completed a physical residual
functional capacity assessment after conducting a
consultative examination of Mr. Motes. (Tr. 413). Dr. Daecher
opined that Motes was capable of frequently lifting and
carrying 20 pounds and occasionally lifting and carrying 100
pounds, but could only occasionally lift above chest height;
had no limitations in standing, walking, sitting, pushing and
pulling; could frequently bend, kneel, stoop, crouch,
balance, and climb; and could occasionally reach. (Tr. 413,
Schneider completed a mental medical source statement of
Motes' ability to do work-related activities on May 28,
2013. (Tr. 428). Dr. Schneider opined that Motes had extreme
limitations in most mental work-related areas, except in the
area of carrying out simple instructions, wherein Dr.
Schneider opined that Motes had marked limitations.
Poloni, a state agency psychologist, reviewed Motes'
claim for benefits on June 11, 2013, and opined that Motes
had moderate restrictions in activities of daily living,
maintaining social functioning, and concentration,
persistence, or pace. (Tr. 85, 90). Despite these moderate
limitations, Dr. Poloni opined that Motes had the mental
residual functional capacity to perform simple, unskilled
work in an isolated setting. (Id.). Dr. Poloni
further opined that Dr. Schneider's opinion should be
accorded little weight because his extreme findings were
inconsistent with the medical evidence. (Tr. 90).
Miller also completed a physical residual functional capacity
assessment, as well as a diabetes mellitus residual
functional capacity assessment. (Tr. 438, 493). Ms Miller
opined that Motes could frequently lift and carry less than
10 pounds; sit for less than 2 hours, and stand and/or walk
for 6 hours in an 8hour day. (Tr. 440, 494). She provided
that he could occasionally perform postural activities; he
should avoid all exposure to extreme heat, humidity, wetness,
and pulmonary irritants; that he was limited in the use of
his hands and fingers; and that he could not reach overhead.
(Tr. 440-41, 495-96). Ms. Miller further opined that Motes
needed to change positions at will; needed to take
unscheduled breaks; that he constantly experienced pain or
other symptoms severe enough to interfere with attention and
concentration; and that he was incapable of even low stress
jobs and would likely be absent from work more than four days
per month. (Tr. 439-41, 493-96).