United States District Court, D. Massachusetts
REPORT AND RECOMMENDATION
DAVID H. HENNESSY, Magistrate Judge.
The Plaintiff, John Connor, seeks reversal of the decision by the Defendant, the Commissioner of the Social Security Administration ("the Commissioner"), denying him Disability Insurance Benefits ("DIB"), or, in the alternative, remand to the Administrative Law Judge ("ALJ"). (Docket #17). The Commissioner seeks an order affirming her decision. (Docket #19).
By Order of Reference dated October 6, 2015, pursuant to 28 U.S.C. § 636(b)(1)(B) (Docket #22), this matter was referred to me for a Report and Recommendation on these two motions which are now ripe for adjudication.
For the reasons that follow, I RECOMMEND that Connor's Motion to Reverse (Docket #17) be DENIED and Defendant's Motion for Order Affirming the Decision of the Commissioner (Docket #19) be ALLOWED.
A. Procedural History
Connor filed an application for DIB on October 6, 2011, alleging that he had been disabled since June 17, 2011. (Tr. 181). The application was denied initially and on reconsideration. (Tr. 65-93). Following a July 12, 2013 hearing, the ALJ rendered a decision unfavorable to Connor on September 6, 2013. (Tr. 20-38).
The ALJ found that Connor had not been disabled from June 17, 2011, through the date of the decision. (Tr. 33). On September 22, 2014, the Appeals Council denied Connor's request for administrative review, making the ALJ's decision final and ripe for judicial review. (Tr. 1-5). Having timely pursued and exhausted his administrative remedies before the Commissioner, Connor filed a complaint in this Court on November 6, 2014, pursuant to 42 U.S.C. § 405(g). (Docket #1). Connor filed the motion for reversal or remand on April 20, 2015, (Docket #17), and the Commissioner filed a cross-motion on June 1, 2015, (Docket #19). On June 14, 2015, Connor filed a reply to the Commissioner's motion. (Docket #21).
B. Personal History
At the time that he claims he became disabled, Connor was 47 years old. (Tr. 181). Connor is a high school graduate and possesses a driver's license. (Tr. 45, 200). He is married and lives with his wife and two daughters. (Tr. 45).
Between 1989 and the alleged disability onset date of June 17, 2011, Connor worked forty-six hours per week as a foreman at a warehouse distribution center. (Tr. 200). As foreman, Connor supervised thirty other employees and oversaw the distribution of health and beauty products to approximately six hundred store locations across ten states. (Tr. 201). Connor stated that he stopped working in part due to his conditions, and, in part, because he "was unable to work with his superior due to strong disagreements." (Tr. 199). Connor indicated that "[h]is boss is married to [Connor's] ex-wife and this only served to exasperate [Connor's] mental conditions." (Id.).
C. Medical History
As of August 24, 2010, Connor was being treated for borderline diabetes mellitus. (Tr. 315). At that time, treating physician Dr. Guarnieri approved Connor's request to be prescribed Lyrica for his neuropathic pain. (Tr. 315-16).
On June 19, 2011, Connor was hospitalized following a suicide attempt culminated by "several stressors building over the years." (Tr. 272-76, 292). He reported feeling depressed for years, increasing over time, as well as feelings of helplessness and worthlessness. (Tr. 273). He also experienced decreased energy, decreased sleep, and anhedonia. (Id.). Connor was discharged from the hospital on June 28, 2011. (Tr. 271).
Connor began regular psychiatric treatment on June 29, 2011 with licensed mental health counselor Leveille. (Tr. 887-90). His diagnoses included major depressive disorder and he was assigned an initial Global Assessment of Functioning ("GAF") score of 45. (Tr. 889).
On July 7, 2011, Connor told nurse practitioner Sergeant that he was "feeling much better and is sleeping well" after he stopped working but still had a depressed mood. (Tr. 797). Connor reported symptoms of pain, weakness, atrophy, abnormal gait, decreased coordination, paresthesias, numbness, tingling, anxiety, memory problems, and altered concentration. (Id.). A physical exam revealed tenderness to palpation in the thoracic and lumbosacral spine, decreased range of motion, and a positive straight leg raise. (Id.). Sergeant added an antidepressant and told Connor to exercise daily, meditate, and maintain a healthy diet. (Tr. 798). On July 21, 2011, Connor reported to Sergeant that his depression had taken a milder form and that he felt in control of his mood. (Tr. 795). He also reported numbness in both thighs. (Id.).
In August of 2011, an electromyography confirmed evidence of polyneuropathy and right median mononeuropathy indicating carpal tunnel syndrome. (Tr. 327). An MRI taken later that month revealed "very mild degenerative changes, " with a "shallow broad-based disc protrusion" at L4-L5, "with no significant spinal canal, lateral recess or neural foraminal compromise." (Tr. 686). On September 22, 2011, Connor complained to Sergeant of pain in his lower extremities, in response to which Sergeant prescribed him Nucynta. (Tr. 790).
On October 6, 2011 at a follow-up appointment with Sergeant, Connor reported that his depression seemed worse. (Tr. 789). At an appointment with counselor Leveille on October 19, 2011, Connor reported that he had "a difficult time leaving his house, because he is afraid something bad is going to happen." (Tr. 880). On November 9, 2011, Connor reported to Leveille that he felt frustrated that he was not showing improvement mentally, and felt overwhelmed, had difficulty leaving his home, was not sleeping, and had poor concentration. (Tr. 879). Connor indicated that the medications he had been prescribed were not working. (Id.). Sergeant had adjusted Connor's psychiatric medication several times between July and October 2011. (Tr. 787-96).
In November 2011, Dr. Breen assessed Connor with "some element of peripheral neuropathy" and "a moderately significant carpal tunnel syndrome bilaterally." (Tr. 651). Dr. Breen informed Connor that his treatment options included surgical decompression or a corticosteroid injection. (Id.). Connor opted for a relatively noninvasive treatment at first which Dr. Breen thought was reasonable. (Id.). Dr. Breen administered an injection in Connor's left carpal tunnel on November 22, 2011. (Id.). On December 13, 2011, Dr. Breen noted that "[Connor] did very well after the injection and says that he does have decreased pain and numbness and some increased grip strength on that side. He does report that he continues to have pain and numbness on that side and this has been improved after the injections." (Tr. 645). Connor elected to have an injection in his right carpal tunnel on that date. (Id.).
On December 14, 2011, Connor was examined by nurse practitioner Loretz for a vascular evaluation. (Tr. 642-44). Noting that he was overweight, Loretz assessed Connor with "adequate arterial circulation with no evidence of peripheral arterial disease" as well as asymptomatic abnormalities of the veins in Connor's legs. (Tr. 643). Loretz also observed distal forefoot neuropathy which she suspected could be related to diabetes mellitus. (Id.). Loretz prescribed knee-high compression stockings. (Id.).
In December 2011, Sergeant offered opinions concerning Connor's physical and mental RFC. (Tr. 817-25). Sergeant opined that Connor's pain and other symptoms would interfere constantly with the attention and concentration required to perform even simple work tasks and that he was only capable of low stress jobs. (Tr. 818). Sergeant further opined that Connor could walk one city block without rest or severe pain, had significant limitations with reaching, handling, or fingering, could sit for no longer than thirty minutes and stand no longer than fifteen minutes, could sit and stand/walk for about two hours in an eight-hour work day, would need a job that permits shifting positions at will from sitting, standing, or walking, and would need to take unscheduled breaks every thirty minutes lasting five minutes. (Tr. 818-19). Sergeant concluded that Connor would likely be absent from work more than four days per month. (Tr. 820, 824). Sergeant stated that the assessed symptoms and limitations applied beginning in 2005. (Tr. 820, 825).
Later that month, Connor underwent a one-time consultative examination with psychologist Dr. Kissin. (Tr. 627-34). Connor received a score of thirty out of thirty points on the Mini-Mental Status Exam, "evidencing no notable deficits in his gross cognitive skills." (Tr. 631). Dr. Kissin stated that Connor's presentation "was appropriate to content without visible distress, " "[h]is attention and concentration were grossly intact, " and "his thought process was coherent, goal directed and reality-based." (Tr. 630-31). Dr. Kissin did note that Connor reported feeling anxious and depressed and nervous about potential harm from others. (Tr. 630). Dr. Kissin found that, in light of his poor response to medications taken to date, Connor's psychiatric medications may require adjustment "in order to effect optimal mood stabilization." (Tr. 631-32). Dr. Kissin assigned Connor a GAF score of 65. (Tr. 631).
On January 11, 2012, Connor was seen by Dr. Rade at the UMass Memorial Cardiovascular Clinic. (Tr. 639-40). Dr. Rade reported that Connor was doing "extremely well" and had no further symptoms of head or neck discomfort following an increase of his metroprolol dose. (Tr. 639). While noting some trace pedal edema, Dr. Rade concluded that Connor was "Currently asymptomatic from a cardiovascular standpoint." (Tr. 640).
At a February 2, 2012 appointment with Sergeant, Connor rated his back pain at a six to seven out of ten with Percocet. (Tr. 777). Later that month, he stated that his back pain was a seven out of ten and that he still feels "blue." (Tr. 775). On March 17, 2012, Sergeant assigned Connor a GAF of 70 noting that he had a flat affect, had difficulty staying on task if the task was complex, was able to travel, got along well with others, did chores at home, and had a fair prognosis. (Tr. 799-801). On March 22, 2012, Leveille assigned Connor a GAF of 45, observing that Connor experienced depression, ...