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VanHorn v. Saul

United States District Court, M.D. Pennsylvania

September 11, 2019

MARK D. VANHORN, Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.

          Brann Judge.


          Martin C. Carlson United States Magistrate Judge.

         I. Introduction

         The Supreme Court has recently underscored for us the limited scope of our review in the field of Social Security appeals, noting that:

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).

         For 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).

         This 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.

         Mindful 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.

         II. Statement of Facts and of the Case

         VanHorn 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. 102-03).

         VanHorn 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).

         In 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).

         VanHorn 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).

         In 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).

         VanHorn 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. 130).

         On 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.)

         VanHorn 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).

         It was 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 hearing. (Id.)

         Following 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).

         The ALJ 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.)

         Having 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. (I ...

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