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Pinca v. Berryhill

United States District Court, M.D. Pennsylvania

May 1, 2018

NANCY BERRYHILL Acting Commissioner of Social Security, Defendant


          Martin C. Carlson, United States Magistrate Judge

         I. Introduction

         In evaluating Social Security appeals we are enjoined to apply a deferential standard of review, which calls upon us simply to determine whether substantial evidence, a quantum of proof that is less than a preponderance but more than a scintilla of evidence, supports the ALJ's findings. Governed by this deferential standard of review we turn to the instant case, a Social Security appeal brought by Linda Susan Pinca challenging the adverse decision of an Administrative Law judge (ALJ), who denied her claim for disability benefits. Ms. Pinca asserted before the ALJ, and on appeal, that the combined effects of her lumbosacral myofascitis, fibromyalgia, diabetes mellitus, hypothyroidism, trochanter bursa tenderness, obstructive sleep apnea, hypokalemia, hyperlipidemia, and osteoarthritis of the right knee were totally disabling. However, a medical consultant, who reviewed Pinca's treatment records, found that she could perform an array of light work. Moreover, while Pinca's treating physician submitted reports opining that she was disabled, those reports were contradicted by the doctor's own examination and treatment results, which thoroughly documented numerous benign or essentially neutral medical findings. Recognizing the equivocal nature of this medical record, and given the very deferential standard of review which applies here, for the reasons set forth below, we conclude that the ALJ's decision is supported by substantial evidence and is adequately explained in a written decision that conforms to the legal and regulatory guidelines governing Social Security claims. Accordingly that the decision will be affirmed and the plaintiff's appeal will be denied.

         II. Statement of Facts

          Linda Susan Pinca is in her early 60's and was approximately 52 years old at the time of the alleged onset of her disability in 2008. Pinca has an associate's degree education, (Tr. 27), and from 2002 through 2008, worked for the Commonwealth of Pennsylvania, at the Pennsylvania Higher Education Assistance Agency (PHEAA), (Tr. 37; Tr. 133), serving as the department secretary in Records Management before being promoted to a position of department secretary for the Human Resources office. (Tr. 38.)

         For a number of years, Pinca experienced low back pain at work, (Tr. 508), but Pinca alleges that this back pain became disabling by the Summer of 2008, when she left her employment at PHEAA. The onset of Pinca's claimed disability appears to have coincided with her being laid off from her employment. As Ms. Pinca explained to her pain management physician, Dr. Cho, in June of 2008:

The patient stated the state plans to have lay offs, and she will be laid off from 6/27. She would like to get benefits continuously, and then wants to apply for disability. I requested the patient to call the state disability to send a form for me to fill out.

(Tr. 456.)

         In fact, consistent with his June 2008 treatment notes, over a span of years Dr. Cho completed a number of disability forms for the state retirement system indicating that Pinca was not able to work regularly. (Tr. 473-87.) These periodic reports submitted by the doctor to the state retirement system stood in stark contrast, however, to Dr. Cho's actual treatment records documenting his care and treatment of Pinca from 2008 through 2014. (Tr. 376-461.) Those treatment notes and examination records consistently reported that Pinca responded well to her medication; reported improvement in her condition over time; generally stated an ability to sleep through the night on Pinca's part; and often reported that she experienced clear cognition. (Id.) These medical treatment notes also documented a significant range of motion in Pinca's cervical spine and shoulder, while confirming some restrictions in her lumbar spine mobility. Pinca's examination results likewise revealed either essentially normal, or only very mildly limited, range of motion of her spine, normal strength in her legs, negative straight leg raises, and normal reflexes. (Tr. 387; 390; 392-427; 429; 431-40; 442-45; 449; 451; 453-55; 457.) Furthermore, those treatment notes repeatedly found that Pinca could “resume all activities, ” a finding which was inconsistent with total disability. (Id.)[1]

         It was against this medical and factual backdrop that the ALJ conducted a hearing into Pinca's disability application on February 17, 2016. (Tr. 32-57.) Ms. Pinca elected to represent herself at this hearing, and she and her spouse testified regarding the limitations she experienced due to her medical conditions. (Tr. 34-52.) A vocational expert also testified. In his testimony, the Vocational Expert explained that Pinca's past work was rated by the Department of Labor Dictionary of Occupational Titles as sedentary in nature, but as she described her job, those job duties would have entailed a range of light work. The Vocational Expert further testified in response to hypothetical questions posed by the ALJ that Pinca could return to her past work, whether rated as sedentary or light work, given the degree of impairment described by the ALJ. (Id.)

         Following this hearing, the ALJ propounded medical interrogatories upon an independent medical expert, Dr. Louis Fuchs. (Tr. 695.) After reviewing Pinca's medical records, Dr. Fuchs opined on March 24, 2016, that she essentially retained the ability to perform light work. (Tr. 696-705.) Specifically, Dr. Fuchs found that Pinca retained the ability to sit for an 8-hour period in a workday, stand for 2 hours, and walk for 2 hours. (Tr. 697.) He further opined that Pinca could lift and carry up to ten pounds continuously, and lift and carry 11 to 20 pounds occasionally. (Tr. 696.) He also stated that Pinca could occasionally reach overhead, frequently operate foot controls, occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl, but never climb ladders or scaffolds. (Tr. 698-99.)

         On May 17, 2016 the ALJ issued a decision denying Pinca's claim for disability benefits. (Tr. 9-19.) In this decision, the ALJ first found at Step 1 of the five-step sequential process that applies to disability claims that Pinca met the insured status requirement of the Social Security Act through December 31, 2013, making hers an essentially closed period claim for benefits from 2008 through December 31, 2013. (Tr. 10, 12.) At Step 2, the ALJ concluded that Pinca had the following severe impairments: lumbosacral myofascitis, fibromyalgia, diabetes mellitus, hypothyroidism, and trochanter bursa tenderness. (Tr. 13.) At Step 3, the ALJ concluded that none of these impairments met a listing which would define her as per se disabled. (Tr. 13-14.)

         The ALJ then found that Pinca retained the residual functional capacity to perform a limited range of light work. Specifically, the ALJ found: “After careful consideration of the entire record, . . . that, through the date last insured, the claimant had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b), except the claimant could occasionally climb ramps or stairs, but never climb ladders, ropes or scaffolds. The claimant could frequently balance and occasionally stoop, kneel, crouch, and crawl.” (Tr. 14.)

         In reaching this conclusion the ALJ assessed the competing medical evidence, and assigned greater weight to the opinions expressed by Dr. Fuchs, the medical consultant, than the views tendered by Dr. Cho. (Tr. 14-18.) The ALJ gave great weight to the opinion of Dr. Fuchs, explaining in this decision that Dr. Fuchs' opinions were congruent with the medical records, which “contained multiple examinations that were within normal limits, and [showed] that the claimant's spinal range of motion was only slightly limited.” (Tr. 17.) Therefore,

Given the consistency between the objective evidence and Dr. Fuchs's limitations, the [ALJ] g[ave] great weight to the medical expert's assessment that [Pinca] could perform light level work, However, due to the normal physical examinations, the [ALJ] g[ave] little weight to Dr. Fuchs assessment that the claimant could only stand/walk for 4 hours during an eight-hour workday. Based on the normal physical examinations, the [ALJ] f[ound] that [Pinca] could stand/walk for 6 hours during an eight-hour workday and perform the full range of light work as defined in the Dictionary of Occupational Titles.

(Tr. 18.)

         In contrast the ALJ afforded little weight to Dr. Cho's medical opinions, finding that:

Although Dr. Cho was the claimant's treating pain management specialist, his assertion that the claimant was unable to do any kind of work was inconsistent with his own findings on examination, Several times throughout the period at issue, [Pinca] reported that her pain medications were effective in managing her pain, and that she had resumed some or all of her activities (see, for example, Exhibit 6F/22, 26, and 33), Further, as indicated by Dr. Fuchs above, although [Pinca] may have had some decreased spinal range of motion, the remainder of the of findings on physical examination were within normal limits, Given the inconsistency between the objective evidence and Dr. Cho's certifications in support of the claimant's state disability claim, the [ALJ] g[ave] Dr. Cho's opinions little weight.


         Having made these findings the ALJ concluded at Step 4 of this analytical process that Pinca could return to her past work, work which the Vocational Expert testified was routinely done at the sedentary level of exertion, but work which the expert stated Pinca had performed at a light level of exertion. (Tr. 18-19.) The ALJ therefore concluded that Pinca was not disabled and denied this application for disability benefits. (Id.)

         This appeal followed. (Doc. 1.) On appeal, Pinca argues that the ALJ erred in the assessment of the medical evidence and in creating an RFC based upon this evidence. Pinca also contends that she met the exacting legal standards for disability as a matter of law at Step 3 of this analytical process since she satisfied all of the requirements of disability listings ...

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