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Walter v. Berryhill

United States District Court, W.D. Pennsylvania

July 19, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION ECF NOS. 16, 18


         I. Introduction [1]

         Michele Ann Walter (“Walter”) brings this action pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3), seeking review of the final determination of the Commissioner of Social Security (“Defendant” or “Acting Commissioner”) denying her application for supplemental security income (“SSI”) benefits under Title XVI of the Social Security Act, 42 U.S.C. §§1381-1383f. (“Act”). This matter comes before the Court on cross-motions for summary judgment. (ECF Nos. 16, 18). The record was developed at the administrative level. For the following reasons, Walter's Motion for Summary Judgment will be denied, and Defendant's Motion for Summary Judgment will be granted.

         II. Procedural History

         Walter filed applications for SSI benefits on September 5 and 26, 2013, claiming a disability onset date of September 5, 2012.[2] (R. at 24, 85, 159-73). She claimed that her inability to work stemmed from her depression/ anxiety DX5/2013; her learning disability; and her back and right hip issues DX 2011. (Id. at 84, 160). Walter was denied SSI benefits on January 22, 2014. (Id. at 98-101). She filed a request for an administrative hearing, which was held on November 9, 2015, before Administrative Law Judge (“ALJ”) John J. Porter. (Id. at 44). Walter appeared with counsel and testified at the hearing. (Id. at 44-83). Alina Kurtanich, an impartial vocational expert, provided testimony concerning the nature of jobs and expectations of employers existing in the national economy. (Id. at 78-83).

         In a decision dated February 23, 2016, the ALJ determined that Walter was not “disabled” within the meaning of the Act. (R. at 13-25). Walter filed a request for review of the ALJ's decision by the Appeals Council, which was denied on June 29, 2017, thereby making the ALJ's decision the final decision of the Commissioner. (Id. at 1-3).

         Walter filed a Motion for Leave to Proceed in Forma Pauperis on August 25, 2017, that was granted on August 29, 2017. (ECF Nos. 1, 2). Thereafter, Walter filed a complaint on August 29, 2017, which was not served until October 2017. (ECF Nos. 3, 5). After being granted an enlargement of time, Defendant filed an answer on January 22, 2018. (ECF No. 8). The parties voluntarily consented to having a United States Magistrate Judge conduct all further proceedings in this case. (ECF Nos. 12, 13). Cross motions for summary judgment followed. The matter has been fully briefed. (ECF Nos. 16-20).

         III. Statement of Facts

         A. Walter's Background

         Walter was born on November 6, 1974, and was forty-one years of age at the time of the hearing. (R. at 52). Walter went no further than the eighth grade. (Id.) She has no vocational or post-secondary education. (Id. at 189). Walter has three children. (Id. at 285). She initially stopped working to take care of her middle child who at that time was just six months of age; her middle child was eleven at the time of the hearing. (Id. at 55). Walter's last job was as a bartender, and she previously worked as an aide at a daycare. (Id. at 189). Walter currently lives with her boyfriend. (Id. at 70).

         B. Medical Records

         The ALJ's decision includes a detailed summary of the medical evidence pertaining to Walter's physical and mental impairments. (R. at 13-24). Walter's challenge pertains to the ALJ's analysis of her mental impairment.

         1.People in Need” Treatment Records

         Dr. Michael Frantz, D.O., treated Walter at People in Need on June 12, June 30, July 21, August 21, and September 22, 2015, for mood, anxiety, and substance issues. (R. at 297-306, 317-19). She sought treatment at People in Need after being referred there by a halfway house. (Id. at 304). At her initial visit, Walter complained of restlessness, fatigue, anxiety, and decreased attention, memory, and concentration, but Dr. Frantz found her attention, memory, and concentration to be fair. (Id. at 304-05). She reported that she was seeing a therapist weekly. (Id.) Dr. Frantz recorded that Walter had a history of low mood, irritability, decreased sleep, and low energy. (Id. at 304). Avoidance, flashbacks, and hyperarousal were discussed. (Id. at 304). He described her affect as anxious with limited insight and judgment. (Id. at 305). He found her thoughts to be linear and goal directed. (R. at 305). He found her speech to be soft and slow. (Id.) He found her to have no evidence of hallucinations, psychosis, or suicidal/homicidal thoughts. Dr. Frantz diagnosed her with a depressive disorder and prescribed various medications. (Id. at 306).

         On June 30 and July 21, 2015, Dr. Frantz recorded that there were mild benefits with change in medication but her symptoms continued to cause distress. (Id. at 300, 302). Dr. Frantz found her to be awake, alert, and oriented to person, place, time, and event; having no suicidal ideation; affect congruent; and her mood, attention, memory, and concentration to be fair. (Id. at 300, 302). On August 21, 2015, Dr. Frantz recorded that Walter was having less distress and tolerating her medication without side effects. (Id. at 298). Dr. Frantz found her to be awake, alert, and oriented to person, place, time, and event; having no suicidal ideation; affect congruent; and her mood, attention, memory, and concentration to be fair. (Id.) On September 22, 2015, Dr. Frantz again described Walter's symptoms as causing her less distress. (Id. at 317). Dr. Frantz again found her to be awake, alert, and oriented to person, place, time, and event; having no suicidal ideation; and her mood to be “better” and her attention, memory, and concentration to be fair. (Id. at 317).

         Walter also treated with Samantha Maxwell, LCSW, at People in Need. On August 25, 2015, Walter was not taking her medication due to problems with her pharmacy and reported problems with anxiety, poor sleep, and agitation. (Id. at 323). Maxwell found Walter to be on edge during the session. (Id.) Maxwell recorded that Walter was cooperative with goal directed and productive speech. (Id. at 324). On September 15, 2015, Walter participated in a therapy session for anxiety and depression. (Id. at 320). Maxwell recorded that Walter responded positively to the fact that soon she would be leaving the halfway house and planned to attend meetings, volunteer, and engage in family counseling once she was released from the halfway house. (R. at 320). Also, on that day, Walter self-reported a reduction in PTSD symptoms with exposure to trauma-related stimuli. (Id.)

         2. Dr. Wesley Sowers' Residual Functional Capacity Questionnaire

         Dr. Wesley Sowers of POWER New Day Outpatient completed a mental residual functional capacity questionnaire on October 8, 2013. (Id. at 277). Dr. Sowers explained that he had treated Walter for four months (seeing her once per month) and found her to have both major depression and anxiety d/o NOS but could not identify when her symptoms began. (Id. at 277-81). Her signs and symptoms included: appetite disturbance with weight change; decreased energy; blunt, flat, or inappropriate affect; feelings of guilt or worthlessness; mood disturbance; difficulty thinking or concentrating; psychomotor agitation or retardation; persistent disturbances of mood or affect; emotional withdrawal or isolation; and emotional lability. (Id. at 278). Dr. Sowers did not diagnose Walter with substance dependence or identify substance dependence as one of Walter's signs or symptoms. (Id. at 277-78)

         Dr. Sowers found Walter to be seriously limited in nearly every “Mental Abilities and Aptitudes needed to do Unskilled Work” category and recorded problems with concentration and motivation, including the ability to remember work-like procedures, carry out very short and simple instructions, maintain regular attendance, sustain an ordinary routine without special supervision, work in coordination with or proximity to others without being unduly distracted, complete a normal workday and workweek without interruptions from psychologically based symptoms, respond appropriately to changes in a routine work setting, get along with co-workers, deal with normal work stress, ask questions, perform at a consistent pace, and maintain socially appropriate behavior.[3] (R. at 279-80). Dr. Sowers believed Walter's impairments or treatment would cause her to miss work three days per month and that her disorders would last or had lasted at least twelve months. (Id. at 281). It is Dr. Sowers' medical opinion that Walter cannot engage in full-time competitive employment on a sustained basis. Finally, Dr. Sowers answered “no” to the question, “If your patient's impairments include alcohol or substance abuse, do alcohol or substance abuse contribute to any of your patient's limitations set forth above?” (Id.)

         3. POWER Outpatient Program Letter

         Wilhelmenia Oakley, POWER's outpatient program manager, informed the disability claims adjuster that on May 21, 2013, Walter was diagnosed with alcohol dependence, barbiturate abuse, cocaine dependence in remission, and cannabis dependence in remission. (Id. at 282). She began treatment on May 30, 2013. On June 18, 2013, she completed orientation and was moved to Intensive Outpatient Level Care where she was required to attend eight hours of group and one hour of individual therapy per week. On July 16, 2013, due to a relapse, she was moved into “Partial Level of Care” and was required to attend sixteen hours of group and two individual sessions per week. Walter stepped down to “Intensive Level of Care” on October 2, 2013. (Id.)

         4. Dr. Charles Kennedy

         On January 9, 2014, Walter underwent a consultative psychological evaluation with Dr. Charles Kennedy. (R. at 284-91). Dr. Kennedy recorded that Walter regained custody of two of her children in December 2013. (R. at 285). Dr. Charles Kennedy recorded that Walter self-reported depression, that she had difficulties with motivation, and that she spent four hours each day feeling tearful, self-isolating, and lying in her bed. (Id. at 286). Walter also self-reported experiences with anxiety with panic attacks that occurred most frequently with crowds and a period of alcohol abuse from February 2013 to May 2013. (Id.) Dr. Kennedy noted that she was tearful throughout the evaluation and had difficulty with serial 7's and spelling the word “world” backwards. (Id. at 287). Dr. Kennedy's exam revealed that Walter's speech was normal, her stream of thought was goal-directed, she was fully oriented, did not have hallucinations or delusions, and that her memory, concentration, judgment, and insight were intact. (Id. at 284-91). Dr. Kennedy diagnosed her with a major depressive disorder, recurrent mild-to-moderate; panic disorder with agoraphobia; and alcohol abuse in early full remission. (Id. at 289). Dr. Kennedy noted her progress was fair and she should reconsider counseling and continue sobriety. (Id. at 290).

         Dr. Kennedy also completed a Medical Source Statement of Ability to do Work-Related Activities on January 9, 2014. (R. at 292-95). Dr. Kennedy found Walter to be mildly impaired with regard to understanding, remembering, and carrying out simple instructions. (Id. at 292). Dr. Kennedy found her moderately impaired with regard to understanding, remembering, and carrying out complex instructions. (Id.) He found that she would be moderately impaired in interacting appropriately with the public, supervisors, and co-workers and in responding appropriately to usual work situations and to changes in routine or work setting. (Id.) Finally, he noted that “[s]obriety should improve [her] prognosis”. (Id. at 293).

         C. Administrative Hearing

         At the hearing before the ALJ on November 9, 2015, the following discussion took place between the ALJ and Evan Wolfson, Walter's counsel:

ALJ: . . . We have no treatment records from Dr. Sowers.
ATTY: Right. Which happens with him, on occasion, Your Honor. But I - - ALJ: Did you try to get them?
ATTY: Yes, we did. Yes, we did. And we actually didn't get any records, other than that RFC. So I understand what your position may be there, and I can appreciate that. I did see that there was the treatment plan summary that was received in 3-F. I can certainly make ...

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