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Motes v. Colvin

United States District Court, M.D. Pennsylvania

April 11, 2017

EUGENE MOTES, Plaintiff,
v.
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY Defendant.

          MEMORANDUM

          Hon. John E. Jones III

         The above-captioned action is one seeking review of a decision of the Acting Commissioner of Social Security (“Commissioner”), [1] denying Plaintiff Eugene Motes' application for Social Security Disability Insurance Benefits (“DIB”), pursuant to 42 U.S.C. § 405(g).

         Disability 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. 15).[2]

         Motes 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).

         A 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.

         Motes 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[3] became ripe for disposition.

         Motes 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.

         I. FACTS

         Motes 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).

         A. Motes' Impairments

         In the 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).

         On 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).

         On 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).

         Motes 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).

         On 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.).

         On 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).

         On May 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).

         On June 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).

         On 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).

         A week 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.).

         B. Residual Functional Capacity Assessments

         On 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, 414).

         Dr. 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. (Id.).

         Dr. 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).

         Ms. 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).

         C. The ...


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