Debra v. Colvin, Civil No. 3:16-CV-1782

DEBRA CASE, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

Civil No. 3:16-CV-1782

UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

August 7, 2017

(Magistrate Judge Carlson)

MEMORANDUM OPINION

I. Introduction

In this Social Security Appeal we are called upon to review three aspects of an Administrative Law Judge's (ALJ) decision denying disability benefits to the plaintiff, Ms. Case. First, we are invited to consider Ms. Case's assertion that the ALJ failed to recognize that her impairments were so severe that she should have been regarded as per se disabled at Step 3 of the five-step analysis that applies in Social Security disability cases. Second, Ms. Case alleges that the ALJ erred in the weighing and consideration of the medical treatment records and opinion evidence in this case. Finally, according to Ms. Case the ALJ erred in evaluating her subjective complaints of pain.

Having carefully evaluated each of these claims, judging these arguments against the applicable standards of review which govern Social Security appeals, for the reasons set forth below, we conclude that substantial evidence supports each of these findings. We also find that the ALJ has adequately set forth the basis for the conclusions reached on these three questions presented in the instant appeal. Therefore, given the standard of review that applies to Social Security Appeals, we will affirm the decision of the Commissioner in this case.

II. Statement of Facts and of the Case

On March 7, 2014, Debra Case applied for Social Security Disability Insurance benefits under Title II of the Social Security Act, alleging that she had experienced an onset of her disability in November of 2011. (Tr. 178-9.) At the time of the alleged onset of disability Case was in her mid-40s, (Tr. 192.), and had a prior employment history as an assembler, packer, personal care assistant, cab driver, and egg packer. (Tr. 196.)

This was Case's second Social Security disability application, a prior application having been denied in September of 2012. (Tr. 122-32.) Thus, while Case alleged that her disability began in November 2011, given this prior unsuccessful application, the relevant period for assessing her ability to work began on September 25, 2012. (Tr. 11, 192.)

According to Case her current claim of disability was based upon a series of aliments including two heart attacks in 2010, neuropathy, fibromyalgia, depression, diabetes, blurred vision, anemia, migraine headaches, poor sleep, and spots on her liver. (Tr. 136-7.) With respect to these medical conditions, the evidence presented to the ALJ was mixed, equivocal, and in some instances supported a finding that Case retained the ability to perform some sedentary work. Thus, with respect to Case's heart condition, the evidence showed that Case experienced heart attacks in May and August 2010. (Tr. 301-03, 400-02.) Following these heart attacks, Case had two stents inserted and was able to return to her work as an egg packer until November of 2011. (Id.) Case also made some lifestyle changes, including cessation of cigarette smoking, which seemed to improve her overall cardiac health. (Tr. 359.) In fact, by the time of her December 2014 administrative hearing before the ALJ, Case denied and cardiac impairment and testified that "my heart is doing pretty good. And that part of my illness seems to be doing okay." (Tr. 55.)

Likewise, with respect to her neuropathy and fibromyalgia, Case's medical history was inconsistent, intermittent, and seemed focused on seeking out disability benefits. For example, in February 2012, at the time of her first disability application, Case began treating with a rheumatologist, Alfred E. Denio III, M.D.,for fibromyalgia. (Tr. 472-75.) At the outset of this medical relationship, Dr. Denio noted that Case "initially focuse[d] on her efforts to obtain disability;" (Tr. 473.) and reported that Case stated that "[s]he was not laid off because of the discomforts, that the company was downsizing." (Tr. 473.) After examining Case in 2012, Dr. Denio concluded that her symptoms were consistent with diffuse fibromyalgia syndrome, (Tr. 472-73.), but found that Case had 5/5 strength and no limitations in range of motion. (Tr. 475.) Dr. Denio also concluded that Case suffered from diabetes, but described that condition in fairly benign terms, stating that his exam only "suggest[ed] a mild accompanying peripheral neuropathy." (Tr. 473.) Dr. Denio recommended a conservative course of treatment for Case, including exercise, and lifestyle changes. (Id.)

Two years then passed without any further apparent documented treatment or evaluation of Case's condition by Dr. Denio. Then in March of 2014, Dr. Denio once again examined Case after her disability lawyer requested a reevaluation. (Tr. 879.) At that time, Case had normal gait and reflexes, (Tr. 880.), but reported widespread pain and fatigue. (Tr. 879.) Dr. Denio assessed Case as experiencing fibromyalgia, diabetic neuropathy, and depression. (Tr. 880.) The doctor also sought to rule out structural back problems, which could have been the source of functionally limiting musculoskeletal pain. (Tr. 880.) Once again, Dr. Deniorecommended a conservative course of treatment for Case consisting of water therapy and behavioral therapy for her pain. (Tr. 880.) Further tests and examinations confirmed these initial findings. Thus, a March 2014 lumbrosacral spine examination revealed only mild degenerative changes. (Tr. 895.) Case returned to Dr. Denio in August 2014 and reported that therapy had not helped and she stopped going after 5 or 6 sessions. (Tr. 898.) Dr. Denio recommended that Case receive nerve conduction testing and use a cane. (Tr. 899.) Follow-up EMG testing in August 2014 showed that Case was experiencing only "mild chronic right S1" radiculopathy and "mild" peripheral neuropathy. (Tr. 864.) A September 2014 MRI of Case's lumbar spine also revealed only "mild" degenerative changes. (Tr. 920.) Notably, nothing in the administrative record suggests that Dr. Denio has ever found that Case was disabled, or wholly unable to perform even sedentary work. Indeed, Dr. Denio does not appear to have opined on this issue at all during his episodic treatment encounters with Case.

With respect to Case's diabetes and any associated retinopathy or neuropathy, Dr. Denio's findings were consistent with those of Dr. Jill E. Nye, who treated Case's diabetes in 2014. (Tr. 946-79.) In April 2014, Dr. Nye evaluated plaintiff's laboratory results and told her that her diabetes was out of control. (Tr. 964-65.) Dr. Nye also recommended exercise, diet and lifestylechanges for Case and advised Case that she would need insulin if she could not reduce her blood sugar levels through diet and exercise. (Tr. 965.) However, Case's neuropathy was described by Dr. Nye as "stable," (Tr. 954.), and a March 2014 vision examination revealed "no signs of diabetic retinopathy." (Tr. 813-14.) Once again, nothing in the administrative record suggests that Dr. Nye ever opined that Case was disabled, or wholly unable to perform even sedentary work.

While Case also indicated in her disability application that she has experienced episodes of depression, her treatment records disclose that she has received only periodic care for this condition, and generally has responded well to that care. This care began in December 2012, when Case underwent an initial psychiatric evaluation with Gurdial N. Singh, M.D. (Tr. 486-87.) At that time Case reported that she "broke down two to three weeks ago" after her son moved out and used abusive language with her. (Tr. 486.) On examination, Dr. Singh reported that Case displayed rapid speech, anxiety and depression, but suffered from no thought disorder, and possessed fair judgment and insight. (Tr. 487.) He diagnosed her with major depression, single episode without psychotic features, and an adjustment disorder with depressed mood. (Tr. 487.) Dr. Singh treated Case with anti-depressants, and when Case returned the next month to work through another family issue Dr. Singh reported that she was "minimally anxious"and was "feeling better about her circumstances at the [sic] this time." (Tr. 488.) In fact, by March 2013, Case was "feeling well, denie[d] any complaints; was eating and sleeping well; had good energy; her mood was controlled; and she had no signs of depression. (Tr. 493.) Dr. Singh further observed that Case "maintain[ed] her interest and pleasure and continue[d] to socialize with others." (Tr. 493.)

In August 2013, Case reported feeling depressed and having problems sleeping. (Tr. 491.) In response, Dr. Singh increased her Wellbutrin and added Ambien. (Id.) Case returned to see Dr. Singh eight months later, in April 2014. (Tr. 825.) At that time Dr. Singh reported that Case had not kept her prior appointment with him, and had become non-compliant with her medication in that she was no longer taking her Wellbutrin. (Tr. 825.) Case reported continued problems with her son and Dr. Singh changed her medication. (Tr. 825.) On examination, plaintiff was cooperative, her speech productive, she felt hurt and depressed, but had no thought disorders or perceptual difficulties. (Tr. 825.) Dr. Singh's final examination of Case took place in June of 2014. (Tr. 848.) At that time the doctor reported that Case was "visibly better" but still complained of depression. (Tr. 848.) Like Case's other treating physicians, there is nothing inthe administrative record which suggests that Dr. Singh ever opined that case's emotional conditions were wholly disabling.

While none of Case's treating sources seem to have opined that she was wholly disabled, there were multiple medical opinions in the administrative record which supported a conclusion that Case could perform a range of sedentary work. For example, On June 13, 2014, Elizabeth Kamenar, M.D., examined plaintiff's records and completed a physical...