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Wolford v. Berryhill

United States District Court, M.D. Pennsylvania

December 15, 2017

LAUREN WOLFORD, 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 Acting Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. (Doc. 1.) Plaintiff filed an application for benefits on August 2, 2013, alleging a disability onset date of November 4, 2013. (R. 60.) After she appealed the initial denial of the claim, Administrative Law Judge (“ALJ”) Theodore Burock held a hearing on August 6, 2015. (Id.) With his Decision of November 9, 2015, the ALJ determined that Plaintiff had not been under a disability as defined in the Social Security Act from August 15, 2012, through March 31, 2014, the date last insured. (R. 70-71.) Plaintiff requested review of the Decision by the Appeals Council (R. 55-56), and the Appeals Council denied review on April 18, 2017 (R. 1-6). With the Appeals Council denial, the ALJ's November 9, 2015, decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on June 6, 2017. (Doc. 1.) In her supporting brief, Plaintiff asserts the ALJ erred on the following bases: 1) he erred in finding that Plaintiff had no severe impairments at step two; 2) he failed to properly weigh opinion evidence; 3) he erred at step three by finding Plaintiff did not meet Listings 12.04 and 12.06; and 4) he erred in his evaluation of Plaintiff's symptoms. (Doc. 12 at 1-2.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly denied.[1]

         I. Background

         Plaintiff was thirty years old on the alleged disability onset date. (R. 96.) She has a GED and past work including as a fast food worker and shipping clerk. (R. 176, 198.) When applying for benefits, Plaintiff claimed that the following conditions limited her ability to work: bipolar disorder, borderline adult ADD, PTSD, diabetes, tendonitis, and high blood pressure. (R. 196.)

         A. Medical Evidence [2]

         On July 2, 2013, Plaintiff was seen by her primary care provider, James E. Bruckart, M.D., because of urinary symptoms and a vaginal discharge. (R. 270.) In the Assessment/Plan portion of the office notes, Dr. Bruckart recorded “[s]he reports good mental function at this time, will recommend evaluation by the psychiatrist to decide if treatment for bipolar or other thought disorder may be needed.” (Id.)

         Following a referral by Dr. Bruckhart for a psychiatry evaluation (R. 279), Plaintiff was seen by Kawish Garg, M.D., on August 13, 2013, at Keystone Behavioral Health. (R. 312.) Plaintiff reported that she had been previously diagnosed with depression and bipolar disorder but had not been on any medication for four or five years. (R. 312-13.) At the time of her visit, Plaintiff said she wanted to go back on medication because she had been experiencing depression. (R. 313.) Plaintiff also expressed concerns about anxiety which she indicated had been going on since childhood but panic symptoms were not as bad as they used to be. (Id.) Dr. Garg characterized Plaintiff's memories of sexual abuse by her mother's boyfriend and babysitter to be more like bad memories than PTSD, and he noted that she screened negative for hallucinations, paranoid thoughts, or phobias. (Id.) Dr. Garg determined that Plaintiff had problems with depression in the context of underlying bipolar disorder and she would benefit from mood stabilizing medications. (R. 314.) He also advised that Plaintiff cut down on her caffeine intake and return in two to three weeks. (R. 314.) Mental Status examination showed the following: appropriate appearance; orientation to person, place, time and situation; unremarkable behavior; appropriate speech; appropriate affect; depressed mood; intact memory; clear consciousness sensorium; average intellect; cooperative attitude; good attention; good reasoning; good impulse control; good judgment and insight; realistic self-perception; logical thought processes; unremarkable thought content; and no suicidal or homicidal ideation. (R. 314.) Dr. Garg assessed bipolar disorder current episode depressed and generalized anxiety disorder with panic attacks. (Id.)

         At her visit with Dr. Garg on September 16, 2013, Plaintiff reported that her depression was getting better but she was noticing more irritability and anger. (R. 309.) She also talked about some memory and focus problems, but she did not think they were related to medication because they preceded her recent prescription. (Id.) Plaintiff's mental status was unchanged from her August visit. (R. 309-10, 314.)

         P. Moskel, M.D., conducted a Disability Evaluation on October 7, 2013. (R. 299-303.) By history, Plaintiff reported to Dr. Moskel that she had recently sought treatment for depression as well as being forgetful and worrisome, symptoms for which she had been treated many years before. (R. 299.) She said she did not like to leave the house and was only comfortable with people she knew well. (R. 299-300.) Plaintiff indicated she was able to do all of her chores including cooking and shopping for food, and she had not had treatment for many years until a few months before the evaluation. (R. 300.) Plaintiff was not receiving any kind of psychotherapy or counseling at the time of her evaluation. (R. 301.) Dr. Moskel made the following Mental Status examination findings: Plaintiff made good eye contact and had no increase or decrease in psychomotor activity; her speech was appropriate in rate, production, content, and spontaneity; her mood was euthenics but with some degree of anxiety; her affect was fully appropriate; her thought processes were logical and rational; her thought content was within normal limits; she had no obvious obsessive-compulsive features, phobias, or unusual somatic preoccupations; nothing suggested suicidal ideation; her attention and concentration were good and she was oriented in all spheres; her immediate, recent, and remote memories were all intact; her fund of knowledge was well within normal limits; her abstract reasoning was intact; her insight and judgment were quite good; her intelligence was estimated to be at least average; and her impulse controls were present. (R. 301-02.) Dr. Moskel diagnosed depressive disorder, NOS with anxiety features and rule out PTSD. (R. 302.) Dr. Moskel provided a Medical Source Statement which included the following assessment:

Regarding the medical source statement for work-related activities; based on today's examination and her current mental status there is really no impairment in her ability to understand instructions whether simple or complex. She seems to be quite intelligence [sic] and has actually a very good abstract reasoning and very good insight. When it comes to getting along with public supervisors and coworkers, although she states she had no trouble in the past most of her jobs did not deal with people that much. Clinically, she seems to be friendly and cooperative in engaging, but by her history it sounds as although [sic] she indeed has a lot of anxiety out in public.

(R. 302.)

         On October 14, 2013, Plaintiff reported to Dr. Garg that her depression was getting better, her mood was improving, and she had better focus. (R. 306.) Plaintiff added that she still got depressed but said it was “not near as bad as it was.” (Id.) The only medication side effect reported was dry mouth. (Id.) Dr. Garg's Mental Status examination was the same as that recorded in August and September except that her mood was euthymic rather than depressed. (R. 306, 309-10, 314.)

         The next office visit notes of record are dated April 27, 2015--over one year after the date last insured. (R. 337.) At this visit, Dr. Garg noted that Plaintiff's Mental Status examination was unremarkable and he found Plaintiff's mood to be euthymic. (R. 338.) Dr. Garg also noted that Plaintiff was taking medications without side effects. (R. 337.)

         B. Opinion Evidence

         State agency reviewer Thomas Fink, Ph.D., reviewed records and provided information concerning Medically Determinable Impairments and Severity (MDI) on November 1, 2013. (R. 99-100.) He opined that Plaintiff's impairments of Diabetes Mellitus and Affective Disorders where non severe and she did not have a combination of impairments that was severe. (R. 99.) In the Psychiatric Review Technique (PRT), Dr. Fink reviewed Listing 12.04 for Affective Disorders and Listing 12.06 for Anxiety-Related Disorders and found that Plaintiff had mild restrictions in her activities of daily living, mild difficulties in maintaining social functioning, mild difficulties in maintaining concentration, persistence or pace, and no repeated episodes of decompensation each of extended duration. (R. 99.) Dr. Fink additionally noted that Plaintiff had only initiated mental health treatment in August 2013 and at recent contacts had improved, and her ADL functioning remained mentally intact. (R. 100.)

         Dr. Garg completed a Mental Impairment Questionnaire on July 16, 2015. (R. 350-55.) Because the opinion was rendered over one year after the date last insured, this opinion is not deemed relevant to the time period at issue, particularly in light of the gap in records noted above.

         C. Hearing Testimony

         At the August 6, 2015, ALJ hearing Plaintiff and her attorney appeared as did a Vocational Expert. (R. 76.) Plaintiff verified that she had not worked since her alleged disability onset date of August 15, 2012. (R. 81-82.) She explained her symptoms related to bipolar disorder: when she was in the depression phase, which could last three to four days, she did not get out of bed and then she would go into the manic phase where she got hyper. (R. 83.) Plaintiff said her ADHD symptoms included difficulty focusing and ...


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