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Harrison v. Berryhill

United States District Court, M.D. Pennsylvania

September 5, 2017

CHARLES J. HARRISON, Plaintiff,
v.
NANCY A. BERRYHILL[1] Acting Commissioner of Social Security Defendant.

          MEMORANDUM OPINION

          Martin C. Carlson, United States Magistrate Judge.

         I. Introduction

         The plaintiff, Charles Harrison, (“Mr. Harrison”) is an adult individual who resides within the Middle District of Pennsylvania. On November 28, 2012, Harrison filed a claim for disability insurance benefits, alleging his disability began on September 21, 2011. This claim was denied in a final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”). He now appeals.

         This matter has been assigned to the undersigned United States Magistrate Judge on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c) and Rule 73 of the Federal Rules of Civil Procedure. (Doc. 13; Doc. 14). Upon a careful review of the administrative record, and following consideration of the arguments of counsel, for the reasons expressed herein, we have found that the final decision of the Commissioner is supported by substantial evidence. Accordingly, we will affirm the Commissioner's decision.

         II. Background and Procedural History

         The record of Mr. Harrison' medical treatment for physical and mental health issues is extensive. On August 16, 2011, a few weeks prior to his alleged September 21, 2011, date of onset of disability, Mr. Harrison underwent back surgery to relieve pressure on his nerve root at L5. About a week after the surgery, Nicholas Pandelidis, M.D., the orthopedist who performed the procedure, noted that Mr. Harrison's leg pain was “much better, ” but he would need physical therapy. (Admin. Tr. 569-70; Doc. 12-15 pp. 4-5). Shortly after his alleged date of onset of disability, Mr. Harrison conducted a work-conditioning physical therapy program at the Drayer Physical Therapy Institute. (Admin. Tr. 498, 516; Doc. 12-12 pp. 48, 66).

         On October 12, 2011, Dr. Pandelidis found Mr. Harrison's sciatica was resolving. (Admin. Tr. 471; Doc. 12-12 p. 21). He indicated that Mr. Harrison “could do light work, but no frequent bending, twisting, or lifting and no lifting greater than 20 pounds. Ultimately he should be able to get back to moderately heavy work. He should not go back to jack hammering.” (Admin. Tr. 571; Doc. 12-15 p. 6). This assessment was upgraded at the next scheduled appointment on November 23, 2011. Based on the evaluation of physical therapists at Drayer, Dr. Pandelidis released Mr. Harrison to “medium duty” work. (Admin. Tr. 572, 593-96; Doc. 12-15 pp. 7, 28-31). Finally, at the next appointment, on December 27, 2011, Dr. Pandelidis released Mr. Harrison back to work without restrictions but also stated he should avoid the heaviest work. (Admin. Tr. 573; Doc. 12-15 p. 8). Dr. Pandelidis reported that although Mr. Harrison's neck mobility was “somewhat decreased, ” his gait was “good” and he had some tenderness but not spasm. Id.

         Dr. Pandelidis referred Mr. Harrison to Ali Yousufuddin, M.D. On March 23, 2012, Dr. Yousufuddin examined Mr. Harrison for his complaint of chronic low back pain that had continued after surgery. (Admin. Tr. 579; Doc. 12-15 p. 14). Dr. Yousufuddin reported that Mr. Harrison's straight leg-raising was normal bilaterally at 90 degrees. (Admin. Tr. 580; Doc 12-15 p. 15). Mr. Harrison's motor strength in his legs was 5/5. Id. He had tenderness over the left sacroiliac joint, but no numbness in his legs or feet. Id. Dr. Yousuffuddin recommended injections at the left lumbar facet and sacroiliac joint. (Admin. Tr. 581; Doc. 12-15 p. 16). Mr. Harrison stated he had fifty percent less pain from his left-sided lower back one month after the injections. (Admin. Tr. 582; Doc. 12-15 p. 17). Dr. Yousufuddin noted Mr. Harrison had “marked tenderness present over the left sacroiliac joint” but that his range of motion was “adequate in all directions” and his straight leg-raising test was again negative. (Admin. Tr. 583; Doc. 12-15 p. 18).

         Mr. Harrison presented at Holy Spirit Hospital with a right arm infection on November 19, 2012. (Admin. Tr. 717; Doc. 12-17 p. 49). Helen Makinde, M.D. reported that Mr. Harrison's gait and musculoskeletal examination was normal. (Admin. Tr. 718; Doc. 12-17 p. 50). His memory was intact, his speech was normal, his affect was appropriate, and his thought content was normal. Id. Mr. Harrison denied any hallucinations and suicidal/homicidal ideation. Id.

         At the request of the state agency, Thomas McLaughlin, M.D. examined Mr. Harrison on February 7, 2013. (Admin. Tr. 780; Doc. 12-18 p. 31). Dr. McLaughlin took note of the fact of Mr. Harrison's 2011 back surgery and also noted that Mr. Harrison continued to complain of back pain. Id. Mr. Harrison also complained to Dr. McLaughlin of knee issues dated back to a high school football injury in 1983 and ACL replacement in both knees. (Admin. Tr. 781; Doc. 12-18 p. 32).

         Dr. McLaughlin opined Mr. Harrison could frequently lift two to three pounds and occasionally ten pounds, and could walk one to two hours a day and sit for eight hours a day with a sit/stand option. (Admin. Tr. 787; Doc. 12-18 p. 38). Dr. McLaughlin further opined that Mr. Harrison could occasionally bend, but never kneel, stoop, crouch, balance, or climb. (Admin. Tr. 788; Doc. 12-18 p. 39). X-rays of Mr. Harrison's knees showed “minor osteoarthritic changes involving the medial and, to a lesser extent, the lateral joint compartments.” (Admin. Tr. 791; Doc. 12-18 p. 42). The x-rays did not show osseous injury or loose body though, and there was no visible joint fluid. Id.

         On April 25, 2013, Mr. Harrison was treated at Holy Spirit Hospital for back pain he experienced after falling off his back porch step a few weeks prior. (Admin. Tr. 872; Doc. 12-19 p. 37). Tamra Helmert, M.D. compared an x-ray of Mr. Harrison's back with old x-ray images of Mr. Harrison from May 23, 2011. (Admin. Tr. 875; Doc. 12-19 p. 40). Dr. Helmert found anatomic alignment of the lumbar spine, with vertebral body heights maintained, intervertebral disc space narrowing at L 4/5 and L5/S1, no compression fracture, and normal sacroiliac joints. Id. Dr. Helmert stated that Mr. Harrison showed “[m]ild degenerative changes with disc space narrowing with facet arthropathy at the level L4/L5 and L5/S1, ” and did not show “acute compression fracture[s] or malalignment.” Id.

         At the request of the state agency, Stanley Schneider, Ed.D. performed a clinical psychological evaluation of Mr. Harrison on May 14, 2013. (Admin. Tr. 797; Doc. 12-18 p. 48). Mr. Harrison reported to Dr. Schneider that he was not receiving any outpatient mental health treatment. (Admin. Tr. 800; Doc. 12-18 p. 51). He also reported that he had been on Zoloft “and had a positive response to the medication.” Id. Dr. Schneider stated that Mr. Harrison was able to perform serial fives, “slowly, but accurately.” (Admin. Tr. 803; Doc. 12-18 p. 54). He further stated that Mr. Harrison “was oriented to date and place” although “[h]e incorrectly name [sic] the day of the week.” Id. Mr. Harrison exhibited no significant memory impairment. Dr. Schneider did note that Mr. Harrison's attention and concentration were impaired, though only mildly. Id. Mr. Harrison told Dr. Schneider that he is able to do light cleaning, cook, and pay bills. (Admin. Tr. 804; Doc. 12-18 p. 55). He also told Dr. Schneider that he has a few friends and goes to church a couple of times a week. Id.

         Dr. Schneider opined that Mr. Harrison had a “mild” restriction on the ability to understand and remember simple instructions. (Admin. Tr. 806; Doc. 12-18 p. 58). He found Mr. Harrison had a “marked” restriction on the ability to carry out complex or simple instructions, the ability to understand and remember complex instructions, and the ability to make judgments on complex work-related decisions. Id. In support of his assessment, Dr. Schneider cited “Chronic pain - low tolerance for sitting. Poor focus.” Id. In the area of interaction with others, Dr. Schneider found Mr. Harrison had “marked” restriction on the ability to interact appropriately with the public, the ability to interact appropriately with co-workers, and the ability to respond appropriately to usual work situations and changes in a routine work setting. (Admin. Tr. 807; Doc. 12-18 p. 59). He found Mr. Harrison had a “moderate” restriction on the ability to interact appropriately with supervisors. Id. In support of those findings, Dr. Schneider cited the fact that Mr. Harrison reported a loss of temper at work and stated to Dr. Schneider, “I've been fighting my whole life.” Id.

         On May 22, 2013, John Gavazzi, Psy.D. reviewed Mr. Harrison's record, including Dr. Schneider's assessment, on behalf of the agency. (Admin. Tr. 135-37; Doc. 12-4 pp. 12-14). Dr. Gavazzi opined that Mr. Harrison “can understand, retain, and follow simple job instructions, i.e., perform one- [sic] and two-step tasks” and that Mr. Harrison “can perform simple, routine, repetitive work in a stable environment.” (Admin. Tr. 136; Doc. 12-4 p. 13). Dr. Gavazzi reported that Mr. Harrison was moderately limited in his ability to do the five following tasks: (1) understand and remember detailed instructions; (2) carry out detailed instructions; (3) interact appropriately with the general public; (4) accept instructions and respond appropriately to criticism from supervisors; and, (5) respond appropriately to changes in the work setting. (Admin. Tr. 136-37; Doc. 12-4 pp. 13-14).

         Milagros Buenaventura, M.D., of Diakon Family Life Services performed a psychiatric evaluation on Mr. Harrison on August 13, 2013. (Admin. Tr. 881; Doc. 12-20 p. 2). Dr. Buenaventura reported that Mr. Harrison was cooperative with good eye contact and that his speech was normal in rate and tone. (Admin. Tr. 882; Doc. 12-20 p. 3). Mr. Harrison appeared appropriately groomed and also appeared his stated age. Id. Mr. Harrison reported to Dr. Buenaventura that he had suicidal ideations at times but he did not think he would harm himself. (Admin. Tr. 882-83; Doc. 12-20 p. 3-4). He said he used to have thoughts about having fights with people but he no longer had those thoughts. (Admin. Tr. 883; Doc. 12-20 p. 4). He had no hallucinations or delusions, though he did think people were out to get him. Id. Mr. Harrison's thinking was goal-directed and he was oriented in three spheres. Id. Dr. Buenaventura found Mr. Harrison's memory to be fair and his intellectual functioning to be average. Id. However, he found Mr. Harrison's judgment to be poor and opined that Mr. Harrison lacked insight. Id. Dr. Buenaventura recommended Mr. Harrison receive counseling from Rosemarie Holland, MA, LPC at Diakon Family Life Services. Id.

         On August 24, 2014, George Wiswesser, M.D. authored a progress note that reported Mr. Harrison had normal energy, was generally cooperative, and had an unremarkable appearance and psychomotor. (Admin. Tr. 920; Doc. 12-21 p. 5). Mr. Harrison's speech rate was normal, his mood was euthymic, and his affect was congruent. Id. His thought process was linear and goal directed. Id. Mr. Harrison was not suffering from any hallucinations or delusions, nor did he have suicidal/homicidal ideations. Id. His cognition was grossly intact. Id.

         On September 17, 2013 Dr. Buenaventura authored a psychiatric progress note. (Admin. Tr. 891; Doc. 12-20 p. 12). Dr. Buenaventura reported that Mr. Harrison's appetite had increased while his energy had decreased. Id. Mr. Harrison's sleep was “not good” and complicated by anxiety. Id. Mr. Harrison's mood was depressed. Id. However, he was generally cooperative and his appearance and psychomotor were unremarkable. Id. His speech rate was normal and his affect was congruent. Id. Dr. Buenaventura observed that Mr. Harrison's thought process was linear and goal directed. Id. He did not suffer from hallucinations or delusions. Id. Mr. Harrison had not suicidal/homicidal ideations and his cognition was grossly intact. Id.

         The next psychiatric progress report, dated October 11, 2013, this time by Dr. Wiswesser again, showed much improvement in Mr. Harrison's condition. (Admin. Tr. 890; Doc. 12-20 p. 11). Specifically, his sleep, energy, and libido were now normal, and his mood was upgraded from depressed to euthymic. Id. The rest of the evaluation categories, which had not shown any issues before, continued to present no issue. Mr. Harrison was still generally cooperative and his appearance and psychomotor were still unremarkable. Id. His speech rate was still normal, and his affect was still congruent. Id. Mr. Harrison still had a linear and goal directed thought process and still did not suffer hallucinations or delusions. Id. He still had no suicidal/homicidal ideations and his cognition was still grossly intact. Id.

         Mr. Harrison continued to present no issue through the conclusion of his treatment with Dr. Wiswesser sometime after August 26, 2014, a span of eight more psychiatric progress reports. (Admin. Tr. 885-89, 920-26; Doc. 12-20 pp. 6-10, 4-10). Mr. Harrison had normal appetite, energy, sleep, and libido. Id. Mr. Harrison was generally cooperative and his appearance and psychomotor were unremarkable. Id. His speech rate was normal, his mood was euthymic, and his affect was congruent. Id. Mr. Harrison had a linear and goal directed thought process and did not suffer hallucinations or delusions. Id. He had no suicidal/homicidal ideations and his cognition was grossly intact. Id. However, the nine reports of repeatedly normal findings were contradicted in nearly every category by Rosemarie Holland, MA, LPC in a single report, which was dated February 12, 2014. (Admin. Tr. 911-16; Doc. 12-20 pp. 32-37).

         At the time of the hearing, Mr. Harrison was divorced with one teenage child. (Admin. Tr. 801; Doc. 12-18 p. 52). He was born in 1964 and is a high school graduate. (Admin. Tr. 288; Doc. 12-7 p. 18). Mr. Harrison has past relevant work as a roll tender and maintenance worker. (Admin. Tr. 50; Doc. 12-2 p. 51).

         Mr. Harrison filed an application for disability insurance benefits under Title II of the Social Security Act on November 28, 2012. After his claim was denied at the initial level of administrative review, a hearing was held on October 28, 2014 before an Administrative Law Judge (“ALJ”). That hearing was continued until January 15, 2015, when the ALJ obtained testimony from a VE who was present at the first hearing. (Admin. Tr. 49; Doc. 12-2 p. 50). The ALJ issued an opinion denying Mr. Harrison's claim on January 26, 2015. (Admin. Tr. 37; Doc. 12-2 p. 38).

         In this opinion at Step One of the five-step sequential analysis process that applies to Social Security disability claims, the ALJ found Mr. Harrison was not working at a substantial gainful activity. (Admin. Tr. 25; Doc. 12-2 p. 26). At Step Two, the ALJ found Mr. Harrison had the following eight severe impairments: (1) degenerative disc disease of the lumbar spine; (2) degenerative joint disease of the knees; (3) major depressive disorder; (4) bipolar disorder; (5) anxiety disorder; (6) substance abuse disorder; (7) ADHD; and, (8) personality disorder. Id. At Steps Three and Four, the ALJ found that Mr. Harrison's severe impairments did not meet or equal a Listing that would cause him ...


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