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Woodman v. Berryhill

United States District Court, M.D. Pennsylvania

January 30, 2018

JEFFREY WOODMAN, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge

         I. Statement of Facts and of the Case

         Jeffrey Woodman was born in 1952, and was approximately 57 years old at the time of this alleged onset of his disability in 2009. (Tr. 187.) At the time of the alleged onset of his disability Woodman had worked for many years in a number of sedentary positions as a sales and marketing manager for cable companies. (Tr. 191.)

         In November of 2013, Woodman applied for Social Security disability and supplemental security income benefits pursuant to Title II and Title XVI of the Social Security Act. (Tr. 21.) In these applications Woodman alleged that he was now wholly disabled due to the combined effects of a fingertip amputation of three fingers on his right hand in a lawnmower accident, depression, anxiety, high cholesterol, skin cancer in remission and an enlarged prostate. (Tr. 190.) Woodman later identified two other ailments which he alleged prevented him from undertaking any substantial gainful activity: sclerosis and joint space narrowing in his left hip as well as a tremor in his left hand. (Tr. 23-4.)

         With respect to these various conditions, the record was both sparse and equivocal in terms of whether any of these conditions, singly or combined, were wholly disabling. At the outset, Woodman's own self-reported activities indicated that he retained some capacity to work after his alleged onset date in 2009 because he, in fact, worked at a number of part-time avocations after 2009. Thus, Woodman was self-employed buying and selling commercial lighting fixtures throughout 2011 (Tr. 201); worked as a fish clerk at a grocery store in 2013 and 2014 (Tr. 265); and worked in sales for Charter Homes and Neighborhoods in 2014 and 2015. (Tr. 42, 265.)

         Likewise, Woodman described an active lifestyle in his reports to Social Security, stating that on a typical day he ate breakfast, looked for employment opportunities, worked from home, exercised, and then ate dinner. (Tr. 231.) According to Woodman, he performed his personal care needs, prepared complete dinners with several courses, did household chores, made household repairs, mowed his lawn, shopped in stores, played the saxophone, and attended “get togethers, ” choir practice, and church services. (Tr. 232-234, 242.) Indeed, Sally Ann Hart, who lived with Woodman at the time of his disability application, when asked how Woodman's medical conditions impaired his ability to work replied: “They don't, to my knowledge.” (Tr. 238.)

         Given these reports from Woodman and his partner regarding his activities of daily living and the lack of any noticeable impairment upon his ability to work, it is not surprising that Woodman offered no medical opinion evidence in support of his claim of total disability. Instead of presenting any medical source opinion statements to confirm that he was unable to work, Woodman simply marshalled various treatment records. However, these records provided, at best, a mixed picture of Woodman's physical health and emotional well-being.

         For example, with respect to his fingertip amputations, these medical records disclosed that in May of 2011, Woodman sought treatment in Lancaster General Hospital emergency room after cutting “the tips of his fingers” on a lawnmower blade. (Tr. 394.) While this mishap led to the loss of three fingertips on his right hand, one month following his surgery Woodman reported that, while he had some numbness and tingling in the distal tips of his index and middle fingers, his symptoms and functioning were improving and he was “doing well.” (Tr. 355.) Dr. Carl Adolph, who treated Woodman, found that Woodman's wounds were closed; he could make a fist; and he had normal range of motion except for some decreased range of motion in his middle finger. (Tr. 355-56.) There is no further indication that Woodman sought additional treatment for his right fingertips. At later appointments with his primary care physician, he did not report any problems/complaints concerning his right fingertips, and Woodman's family doctor, Christopher McLane, M.D., documented intact sensation in his upper extremities. (Tr. 462.) Likewise, Woodman's complaints regarding tremors in his left hand were described as a “mild” tremor that “runs in the family, ” and Woodman did not seek a referral to a neurologist to follow-up on this condition. (Tr. 458, 463.)

         The available medical records also described Woodman's prostate condition in terms that were not wholly disabling. In January 2011, Woodman was diagnosed with benign prostatic hyperplasia (BPH) and reported a slow urinary stream. (Tr. 291.) Woodman was treated for this condition with medication; reported that the medication was not making his symptoms better, but that the symptoms were not getting any worse; and informed the doctor that his “new business [wa]s taking off” (Tr. 291-93.) While Woodman was later seen in June and July 2011, at Lancaster General Hospital for urinary retention, (Tr. 354, 357), Foley catheterization relieved his symptoms, and he was released in a stable condition. (Tr. 354-55, 357-58.) From 2011 through 2015, routine examinations generally disclosed that Woodman's prostate condition was treated through medication and was under control. (Tr. 294-5, 273-5, 297-9, 314, 318-20, 461-6.)

         Further, medical records did not support a finding that Woodman's left hip discomfort was disabling. On this score, in March 2015, Woodman complained of left hip pain to Dr. McLane, denying a specific injury, but he stating that he had been playing “kickball with friends at work.”[1] (Tr. 457.) While Woodman experienced some tenderness to palpation and “a little” tenderness on rotation of his left hip, he appeared to be in no acute distress, walked with a normal gait and station, and had intact neurological functioning. (Tr. 458.) X-rays showed moderate degenerative changes in his hip, (Tr. 472), and while his family physician provided Woodman with medication he did not refer Woodman to physical therapy or an orthopedist. (Tr. 458.)

         Finally, the existing medical records were fairly unremarkable with respect to Woodman's mental and emotional state. Those records disclosed that in January 2011, Woodman reported depression and anxiety, but his treating physician found no unusual anxiety or evidence of depression on examination. (Tr. 292-93.) Consequently, the treating doctor addressed this concern through an anti-depressant prescription. (Tr. 293.) Woodman never sought further treatment from a psychiatrist, psychologist, or therapist, and Woodman's family doctor did not refer him for mental health treatment. (Tr. 450.) At routine follow-up appointments, Woodman's mental status was typically reported to be stable on medication, and his medication prescriptions were refilled. (Tr. 309-14, 318-20, 461-66.) Given this benign treatment history, on January 30, 2014, a State agency psychologist, Richard Williams, Ph.D., the only acceptable medical source to provide any medical opinion in Woodman's case, concluded that Woodman's mental impairments were not severe. (Tr. 63-64.)

         It was against this equivocal medical and factual backdrop that the ALJ conducted a hearing considering Woodman's disability application on July 21, 2015. (Tr. 37-51.) At this hearing Woodman and a vocational expert both appeared and testified. (Id.) The vocational expert testified that a person with Woodman's impairments would be capable of performing his past sedentary, skilled, work in sales and marketing. (Id.)

         Following this hearing, on July 31, 2015, the ALJ issued a decision denying Woodman's application for disability benefits. (Tr. 18-36.) In this decision, the ALJ first found that Woodman met the insured requirements of the Act through June of 2014 and had not worked continuously since June 2009, the alleged onset date. (Tr. 23.) At Step 2 of the five-step sequential analysis process that applies to Social Security disability claims the ALJ concluded that Woodman experienced a severe hip impairment, but found that his remaining medical conditions, while medically determinable, were not severe. (Tr. 23-6.) At Step 3 of this sequential analysis, the ALJ concluded that none of Woodman's impairments met a listing that would define him as per se disabled. (Tr. 26-30.) The ALJ then concluded at Step 4 of this process that Woodman retained the capacity to perform his past relevant marketing work, work which entailed skilled, but sedentary, labor. (Tr. 30.) Having made these findings, the ALJ concluded that Woodman did not meet the statutory definition of disability, and denied his application for benefits. (Tr. 31.) .

         This appeal followed. (Doc. 1.) On appeal, Woodman advances three claims. First, he argues that the ALJ's residual functional capacity assessment was inherently flawed because it was unsupported by any medical opinion. Woodman adopts this position even though he provided no medical opinion evidence in support of his disability claim, and Woodman apparently adopts the categorical view that an expert medical opinion is always required in these cases. Second, Woodman argues that the ALJ erred in failing to order a consultative examination in this case. Finally, Woodman contends the ALJ erred in relying upon ...


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