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Mahoski-Ciarla v. Berryhill

United States District Court, M.D. Pennsylvania

October 19, 2017

JOYCE MAHOSKI-CIARLA, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          RICHARD P. CONABOY UNITED STATES DISTRICT JUDGE

         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act and Supplemental Security Income (“SSI”) under Title XVI. (Doc. 1.) Plaintiff filed applications for benefits on December 31, 2013, alleging a disability onset date of March 19, 2013. (R. 21.) After she appealed the initial denial of the claims, a hearing was held on July 24, 2015, and Administrative Law Judge (“ALJ”) Jarrod Tranguch issued his Decision on December 21, 2015, concluding that Plaintiff had not been under a disability during the relevant time period. (R. 21, 32.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on January 4, 2017. (R. 1-6, 16-17.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on March 7, 2017. (Doc. 1.) She asserts in her supporting brief that the Acting Commissioner's determination is error for the following reasons: 1) his determination that Plaintiff's knee arthritis and anxiety were not severe impairments was error; and 2) he erred in rejecting the opinions of Plaintiff's treating psychiatrist, Dr. Matthew Berger. (Doc. 14 at 3.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly granted.

         I. Background

         Plaintiff was born on April 13, 1961, and was fifty-two years old on the alleged disability onset date. (R. 31.) She has a high school education and past relevant work as a food service supervisor, food service coordinator, and telemarketer. (Id.) Plaintiff alleges she is unable to work on a competitive full-time basis due to right knee arthritis, bipolar disorder, and anxiety disorder with panic attacks. (Doc. 14 at 2.)

         A. Medical Evidence

         1. Primary Care

         a. Right Knee Arthritis

         At a primary care visit on September 30, 2013, Plaintiff complained of right knee pain and stiffness. (R. 373.) At the request of her primary care provider, Leocadia T. Prawdzik, M.D., Plaintiff had x-rays indicated by right knee pain at Hazleton General Hospital on October 11, 2013. (R. 315.) The “Impression” was no acute fracture or dislocation, mild degenerative joint changes, and small joint effusion. (Id.)

         On October 14, 2013, upon Plaintiff's request, Dr. Prawdzik referred Plaintiff for an orthopedic consultation because she reported in a telephone contact that nothing was helping her right knee pain. (R. 372.) Plaintiff reported that her pain was getting worse at her October 16th office visit. (R. 371.) Examination showed that she had pain in the posterior and medial aspects of the right knee with mild swelling, gait dysfunction, and mild right leg swelling. (Id.)

         Plaintiff saw James E. Murphy, M.D., for an orthopedic consultation on October 22, 2013. (R. 387.) Dr. Murphy informed Dr. Prawdzik that Plaintiff reported a four-week history of right knee pain that “started out of the blue” and bothered her when she was walking on flat ground and bending her knee to go up steps. (Id.) Dr. Murphy found that x-rays did not show any significant abnormalities but he thought they showed some mild osteoarthritis. (Id.) He also found that Plaintiff's clinical examination was consistent with “pes tendinitis as she is quite tender right over the spot of the tendon insertion.” (Id.) Dr. Murphy recommended avoidance of aggravating activities, nonsteroidal antiinflammatories, and physical therapy for evaluation. (Id.) He noted that she would follow up with him on an as-needed basis. (Id.)

         On January 8, 2014, Plaintiff reported that naproxin was helping her right knee pain. (R. 368, 473.)

         On May 15, 2015, Plaintiff reported that she had knee pain and the right knee was giving out three times per week. (R. 471.) She said it was worse when walking and she had increased pain when doing steps and standing up from a sitting position. (Id.)

         On June 10, 2015, Dr. Prawdzik noted that Plaintiff had no complaints, and musculoskeletal pain and stiffness were much better with Naproxen. (R. 469.) His diagnoses included degenerative joint disease of the right knee. (Id.)

         b. Anxiety and Depression

         On December 17, 2012, Dr. Prawdzik's diagnoses included anxiety and depression. (R. 378.) In August 2013 Dr. Prawdzik did not make any notation in the ROS “Psych” section and examination findings included that Plaintiff's mental status was within normal limits. (R. 374-75.) He continued to include anxiety and depression in his diagnoses. (R. 375.) In September, Plaintiff continued to report a lot of anxiety. (R. 373.)

         On January 8, 2014, Plaintiff told Dr. Prawdzik she was experiencing increased anxiety which included palpitations and shortness of breath during anxiety attacks. (R. 368, 473.) On May 15, 2015, Plaintiff reported increased anxiety and said she was seeing a therapist and psychiatrist. (R. 471.) Dr. Prawdzik noted that Plaintiff had no complaints in June 2015 but his diagnoses included anxiety and depression. (R. 469.)

         2. Mental Health Treatment

         Plaintiff's treating psychiatrist has been Matthew Berger, M.D., who began treating her in February 2013 upon referral from her primary care provider. (R. 420.) At the initial visit, Dr. Berger recorded that Plaintiff reported symptoms of bipolar disorder, eating disorder, and substance abuse. (Id.) Objectively, Dr. Berger assessed Plaintiff's mood as anxious and depressed with an affect appropriate to that mood. (R. 422.) Otherwise no problems were noted with Plaintiff's psychiatric examination. (Id.) Dr. Berger diagnosed Alcohol Abuse in Remission, Bipolar I Disorder Current Mixed NOS, Eating Disorder Other. (Id.) He assessed a current GAF score of 49. (Id.) Dr. Berger adjusted Plaintiff's medication regimen and scheduled Plaintiff to see a therapist. (R. 423.)

         In June 2013, Plaintiff reported that she was doing well and that seeing the therapist had been very helpful. (R. 416.) Plaintiff continued to report symptoms of bipolar disorder and said she was taking her medications as prescribed but felt worse compared to her previous visit. (Id.) She also reported symptoms of eating disorder and substance abuse including binge eating, body dysmorphia, self-induced vomiting, infrequent diuretic use, and recent alcohol consumption. (Id.) Dr. Berger noted that Plaintiff displayed depression during the encounter and otherwise her psychiatric examination was unremarkable. (R. 418.) Dr. Berger noted that Plaintiff's bipolar illness and eating disorder were ongoing, and her substance abuse was episodic. (R. 418.) His diagnosis remained the same and his GAF score was assessed to be 50. (Id.)

         Dr. Berger's assessments in July, August, and October indicate that Plaintiff's bipolar disorder and eating disorder were improving or stable, and her alcohol abuse was episodic or in remission. (R. 402, 406, 410, 414.) GAF scores of 54-56 were recorded. (Id.) He also noted that Plaintiff had been taking her medication as prescribed. (R. 400, 404, 408, 412.)

         In January 2014, Plaintiff reported a lot of daytime anxiety and rated her mood as 2/10. (R. 396.) She also reported an increase in many bipolar disorder symptoms and said she felt worse compared to her previous visit. (Id.) She said she had not taken all prescribed medications for a one-month period due to insurance problems. (Id.) Plaintiff continued to report symptoms of eating disorder and said she had used alcohol in October. (Id.) Dr. Berger found Plaintiff's affect to be depressed and labile but her psychiatric examination was otherwise normal. (R. 398.) He concluded Plaintiff's bipolar illness was increasing, her eating disorder was stable, and her alcohol abuse was in remission. (R. 398.) He assessed a GAF score of 50.[1] (Id.)

         In February 2014, Plaintiff reported to Dr. Berger that she was “terrible” and her mood had been like a “roller coaster.” (R. 392.) She reported increased bipolar disorder symptoms, some improvement with eating disorder symptoms, and no new episodes of alcohol use. (Id.) Dr. Berger found Plaintiff to be anxious with an affect appropriate to her mood. (R. 394.) He noted that Plaintiff's speech was overproductive and tearful and her judgment and insight were fair. (Id.) Dr. Berger again assessed Plaintiff's bipolar illness to be increasing, her eating disorder to be stable, her alcohol abuse was in remission, and her GAF score was 44. (Id.)

         In March 2014, Plaintiff reported to Teresa Clark, CRNP, that she was “a little better, ” and she felt that her medication adjustment had helped. (R. 434.) She continued to report symptoms of bipolar disorder and eating disorder. (Id.) Ms. Clark noted that Plaintiff's speech was overproductive and tearful, and her judgment and insight were fair. (R. 436.) She assessed that Plaintiff's bipolar disorder was increasing, her eating disorder was stable, and her alcohol abuse was in remission. (Id.) She recorded a GAF score of 44.

         On June 4, 2014, Plaintiff reported to Ms. Clark that she had started drinking again and she been under increased stress due to financial concerns and pressure to take a job managing a small bakery that she knew would be too much for her. (R. 438.) She expressed experiencing symptoms related to bipolar disorder and eating disorder. (Id.) Ms. Clark noted that Plaintiff's mood was subdued with related affect. (R. 440.) She also noted that Plaintiff's speech was overproductive and tearful, her judgment was impulsive, and her insight was lacking. (Id.) She assessed that Plaintiff's bipolar illness was ongoing, her eating disorder was stable, and her alcohol abuse was episodic. (Id.) Ms. Clark again recorded a GAF score of 44. (Id.)

         On June 30, 2014, Plaintiff told Ms. Clark that she had decided not to take the job and she was feeling less overwhelmed since making the decision. (R. 442.) Plaintiff continued to report symptoms of bipolar disorder, eating disorder, and alcohol abuse. (Id.) Plaintiff's examination and assessments were the same as earlier in the month except that she was not tearful. (R. 440, 444.)

         In October 2014, Plaintiff reported to Ms. Clark that she had taken a part-time job and she was doing craft shows with baked goods which was keeping her busy. (R. 446.) She continued to report symptoms of bipolar disorder with a decrease in some symptoms, and she reported a decrease in eating disorder symptoms. (Id.) Ms. Clark again found Plaintiff's mood subdued with her affect appropriate to her mood. (R. 448.) She assessed ongoing bipolar illness, stable eating disorder, episodic alcohol abuse, and a GAF score of 48. (Id.)

         In February 2015, Plaintiff reported an improvement in her mood and Ms. Clark noted that Plaintiff's affect was appropriate to her mood. (R. 452.) Ms. Clark continued to find that Plaintiff's judgment was impulsive and her insight was lacking. (Id.) She assessed that Plaintiff's bipolar illness was improving, her eating disorder was stable, her alcohol abuse was episodic, and her GAF score was 50. (Id.)

         Plaintiff again reported improvement to Ms. Clark in April 2015, stating that she knew she took on too much at times and was trying to keep things in perspective. (R. 454.) She also reported that she was busy baking for weekend craft shows, and she was working six to nine hours a week which helped with the bills. (Id.) Plaintiff continued to express that she had symptoms of bipolar disorder but stated they had decreased, as had her symptoms of eating disorder. (Id.) Ms. Clark recorded that Plaintiff's mood was euthymic and her affect was appropriate but her judgment continued to be impulsive and her insight was lacking. ...


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