United States District Court, M.D. Pennsylvania
MARK D. VANHORN, Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
C. Carlson United States Magistrate Judge.
Supreme Court has recently underscored for us the limited
scope of our review in the field of Social Security appeals,
The phrase “substantial evidence” is a
“term of art” used throughout administrative law
to describe how courts are to review agency factfinding.
T-Mobile South, LLC v. Roswell, 574 U.S. __, __, 135
S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the
substantial-evidence standard, a court looks to an existing
administrative record and asks whether it contains
“sufficien[t] evidence” to support the
agency's factual determinations. Consolidated Edison
Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed.
126 (1938) (emphasis deleted). And whatever the meaning of
“substantial” in other contexts, the threshold
for such evidentiary sufficiency is not high. Substantial
evidence, this Court has said, is “more than a mere
scintilla.” Ibid.; see, e.g.,
Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal
quotation marks omitted). It means-and means only-“such
relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Consolidated
Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson
v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d
143 (1999) (comparing the substantial-evidence standard to
the deferential clearly-erroneous standard).
Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019).
Administrative Law Judges (ALJs), Social Security disability
determinations frequently entail an informed assessment of
medical records coupled with an evaluation of a
claimant's subjective complaints. Once the ALJ performs
this task, on appeal it is the duty and responsibility of the
district court to review these ALJ findings, judging the
findings against a deferential standard of review which
simply asks whether the ALJ's decision is supported by
substantial evidence in the record, see 42 U.S.C.
§405(g); Johnson v. Comm'r of Soc. Sec.,
529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue,
901 F.Supp.2d 533, 536 (M.D.Pa. 2012), a quantum of proof
which “does not mean a large or considerable amount of
evidence, but rather such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.”
Pierce v. Underwood, 487 U.S. 552, 565 (1988).
case involves an appeal from what was a largely favorable
disability determination. In the instant case, Mark VanHorn
filed a Title II application for a period of disability and
disability insurance benefits, as well as a Title XVI
application for supplemental security income on August 26,
2016. In his applications, VanHorn alleged disability
beginning on July 5, 2016 due to impairments he had with his
legs, hip and knee, injuries which partially arose from a
work-related accident that VanHorn experienced in 2016. On
this score, the ALJ was presented with medical records and
VanHorn's own testimony. The ALJ found that, while
VanHorn had several severe impairments, VanHorn's own
testimony as to the severity of these impairments was
inconsistent with the medical evidence. Thus, the ALJ issued
a partially favorable decision, finding that VanHorn was not
disabled from July 5, 2016 to April 16, 2018, but finding
that he was disabled beginning on April 16, 2018, given the
Grid Rules governing age categories.
of the fact that substantial evidence “means
only-'such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion, '”
Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019),
we find that substantial evidence supported the ALJ's
findings in this case. Therefore, for the reasons set forth
below, we recommend that the district court affirm the
decision of the Commissioner.
Statement of Facts and of the Case
applied for a period of disability and disability insurance
benefits, as well as supplemental security income on August
26, 2016. (Tr. 53). He alleged total disability beginning on
July 5, 2016 due to impairments with his knee, hip, and lower
back. (Tr. 257). VanHorn was an individual closely
approaching advanced age, as he was almost 53 years old on
the alleged onset date. (Tr. 133). He had a high school
education and past work as a construction worker. (Tr.
was injured at work on July 5, 2016. (Tr. 633). He was
working on a pipeline project and had gotten caught between
two rocks that had shifted. (Id.) His coworkers were
able to free him, and he presented at Williamsport Regional
Hospital on July 9, where he was diagnosed with a muscle
strain of the right quadriceps. (Tr. 474-75). VanHorn was
seen again at Williamsport Regional on July 18, where he was
diagnosed with traumatic bursitis of the right hip. (Tr.
588). It was noted that VanHorn was having difficulty
walking, and that he was experiencing aching and pain in his
right hip, ankle and knee. (Tr. 591).
August 2016, VanHorn was diagnosed with acute right hip pain;
spinal stenosis, lumbar region, with neurogenic claudication;
lumbosacral radiculopathy and L5; and primary osteoarthritis
of the right knee. (Tr. 506, 510-11). He was referred to
physical therapy two times per week for four weeks for pain
relief and increased function. (Id.) Marc Galin,
CRNP, at Susquehanna Health wrote a note for VanHorn stating
that he was only able to engage in sedentary work activities
for one month. (Tr. 508).
then began treating at Phoenix Rehabilitation and Health
Services with Dr. Amy Farrer, D.P.T. On August 29, it was
noted that VanHorn's pain was radiating down his right
leg at the hip, knee and lower leg, but that his pain was a
one out of ten. (Tr. 522). Dr. Farrer's treatment plan
included electric stimulation, manual therapy, mechanical
traction, neuromuscular re-education, and therapeutic
activities and exercises. (Tr. 525). Upon his initial visit
at Phoenix, VanHorn filled out a questionnaire, in which he
marked that he had moderate pain, and that his pain prevented
him from walking more than 0.25 miles. (Tr. 543). Notably,
VanHorn did not check the box stating that he needed a stick
or crutches to help him walk. (Tr. 543-44).
September, it was noted that VanHorn had poor tolerance for
exercise tasks, and that his pain was the same. (Tr. 532).
When he returned to Susquehanna Health for a follow-up, it
was noted that his pain was worse after finishing physical
therapy than before he started. (Tr. 567). CRNP Galin then
sent him for an MRI and again limited him to sedentary work.
(Tr. 569, 571). Also in September, VanHorn filled out a
Function Report, in which he stated that he had difficulty
walking, but noted that he did not use any assistive device,
i.e. crutches, walker, cane, wheelchair, and that no
assistive device had been prescribed to him. (Tr. 272). The
MRI from September 29 showed posterior disc bulging, disc
protrusion, and disc herniation, and VanHorn was diagnosed
with lumbar radiculopathy, lumbar disc displacement, lumbar
disc degeneration, and lumbar spondylolisthesis. (Tr. 608).
was also examined by a state agency consultant, Dr. James
Butcofski, on September 23, 2016. (Tr. 124). Dr. Butcofski
opined that VanHorn could perform light work with additional
limitations. (Tr. 128-31). Dr. Butcofski stated that VanHorn
could occasionally climb ramps and stairs, balance, stoop,
kneel, crouch and crawl, but could never climb ladders,
ropes, or scaffolds. (Tr. 129). He also opined that VanHorn
would need to avoid concentrated exposure to heights. (Tr.
November 4, 2016, VanHorn was treated by Dr. Ashok Kumar,
M.D., for his lower back pain. (Tr. 633). VanHorn rated his
pain at a seven or eight out of ten, noting that the pain was
intermittent and continuous. (Id.) Dr. Kumar noted
that he had an antalgic gait, that he bears weight on his
left leg, and that he could not walk on his heels and toes.
(Tr. 635). However, it was also noted that his motor strength
in his right lower extremity was 4/5. (Id.)
was seen by Dr. Ronald DiSimone, M.D., on November 7, 2016.
Dr. DiSimone's examination revealed a bulging lumbar disc
and spinal stenosis, lumbar region, with neurogenic
claudication. (Tr. 653). Dr. DiSimone's plan was to refer
VanHorn to a pain management specialist and limited him to
limited duty at work for several months. (Tr. 564-55). On
April 12, 2017, Dr. DiSimone assessed VanHorn as having
chronic bilateral low back pain with right-sided sciatica and
lumbosacral radiculopathy at ¶ 5. (Tr. 658). Dr.
DiSimone's plan had VanHorn continuing his home exercises
and taking over-the-counter anti-inflammatories, and limited
VanHorn to limited duty for the next three months.
(Id.) This limited duty restriction involved no
lifting, pushing or pulling more than 15 pounds; no climbing
ladders; no repetitive stooping or bending; and the freedom
to sit, stand and walk intermittently. (Tr. 659). However,
Dr. DiSimone noted that VanHorn did not need an assistive
device. (Tr. 663). On May 17, Dr. DiSimone reported that
VanHorn had a walking intolerance after about 500 feet, and a
15-minute standing intolerance. (Tr. 671). He also observed
that the plaintiff's symptoms had been relatively stable.
(Id.) He again limited VanHorn to his prior work
restrictions but limited him to these restrictions
indefinitely. (Tr. 674).
against the factual and medical backdrop that the ALJ
conducted a hearing into VanHorn's disability application
on February 8, 2018. (Tr. 92-123). The plaintiff and a
Vocational Expert both appeared and testified at this
this hearing, on April 20, 2018, the ALJ issued a partially
favorable decision denying VanHorn's application for
disability benefits from July 5, 2016 to April 16, 2018, but
finding that VanHorn was disabled as of April 16, 2018 due to
the age categories and Grid Rules. (Tr. 53-63). In this
decision, the ALJ first found that VanHorn met the insured
requirements of the Act, (Tr. 55), and then at Step 2 of the
five-step sequential analysis process that applies to Social
Security disability claims, found that VanHorn's had the
following severe impairments: spondylosis and degenerative
disc disease of the lumbar spine with lumbosacral
radiculopathy; osteoarthritis of the right knee; and history
of pelvic fracture. (Tr. 56).
then found that none of these impairments met the criteria of
a Social Security listing, which would have prescribed
VanHorn as per se disabled. (Id.)
Specifically, the ALJ found that VanHorn did not meet listing
1.04 (Disorders of the Spine) because the medical evidence
did not indicate that VanHorn had pseudoclaudication with the
inability to ambulate effectively. (Id.)
made these findings, the ALJ concluded that VanHorn had the
residual functional capacity to perform a range of light work
as defined in 20 CFR 404.1567(b) and 416.967(b) with
additional exertional limitations. (Tr. 57). In making this
determination, the ALJ considered the medical evidence
presented along with VanHorn's subjective complaints. The
ALJ gave limited weight to the limitations prescribed by CRNP
Galin and PA-C Krikorian, as they were not acceptable medical
sources. (Tr. 60). The ALJ gave partial weight to the opinion
of Dr. DiSimone, reasoning that his opinion was only
partially consistent with the medical evidence.