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Coe v. Colvin

United States District Court, D. Massachusetts

June 15, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant.



         I. Introduction

         This is an action for judicial review of a final decision by Carolyn Colvin, the Acting Commissioner of the Social Security Administration (“Commissioner”), regarding an individual’s entitlement to Social Security Disability Insurance (“SSDI”) benefits pursuant to 42 U.S.C. § 405(g) and Supplemental Security Income (“SSI”) pursuant to 42 U.S.C. § 1383(c)(3). Kristin Marie Coe (“Plaintiff”) asserts the Commissioner’s decision to deny her such benefits-memorialized in a November 20, 2013 decision of an administrative law judge (“ALJ”)-was in error. Plaintiff has filed a motion for judgment on the pleadings and the Commissioner has moved to affirm. For the reasons set forth below, the court allows the Commissioner’s motion (Dkt. No. 17) and denies Plaintiff’s motion (Dkt. No. 13).

         II. Background

         A. Procedural History

         Plaintiff applied for SSDI and SSI on May 27, 2009 and alleged disability since October 15, 2007. (Administrative Record (“A.R.”) 120-130.) Plaintiff was notified by the Social Security Administration that her claims had been initially denied on or about September 1, 2009, and had subsequently been denied upon reconsideration. (Id. at 55-58, 63-68.) Plaintiff requested a hearing in front of an administrative law judge, which took place on May 12, 2011. (Id. at 8-16.) In a written decision, the ALJ determined Plaintiff was not disabled. (Id.) The Appeals Council denied Plaintiff’s request for review, rendering the ALJ’s decision final and ripe for judicial review. (Id. at 5-7.) Plaintiff filed a complaint in the U.S. District Court on October 14, 2011. On June 8, 2012, the court granted the Commissioner’s assented-to motion for remand, which sought to have the ALJ re-evaluate certain evidence and further consider Plaintiff’s residual functional capacity (“RFC”). (Id. at 740.)

         On November 20, 2013, the ALJ on remand again found Plaintiff not disabled. (Id. at 670-692.) On January 8, 2015, the Appeals Council denied Plaintiff’s request for review and the ALJ’s decision became final and ripe for judicial review. (Id. at 660-64, 665-69.) Thereafter, Plaintiff filed the instant action, the commissioner compiled the administrative record, and the parties filed the cross-motions presently at issue.

         B. Medical History on Record

         Plaintiff alleges disability due to anxiety, depression, attention deficit hyperactivity disorder (“ADHD”), and fibromyalgia. (Id. at 154.) Plaintiff was 27 years old on the alleged disability onset date of October 15, 2007. (Id. at 673, 690). She received her GED and her previous work experience has been that of a store clerk, dishwasher, machine operator, pharmacy clerk, and teacher’s aide. (Id. at 155, 160.)

         On December 23, 2008, Dr. Lawrence Ufford conducted an initial neurological examination of Plaintiff. (Id. at 205-07.) At this appointment, Plaintiff reported recent falls and a previous diagnosis of fibromyalgia. (Id.) Dr. Ufford detected sixteen possible trigger points and suspected “that [Plaintiff’s] falls are related to focal symptomatology at the knee and surrounding insertions, perhaps related to post-traumatic arthritic change or fibromyalgia.” (Id. at 206-207.) At this examination, Plaintiff denied drug and alcohol use and her medications consisted of Adderall, Valium, and Motrin. (Id. at 206.) On January 16, 2009, Dr. Ioana Stanescu conducted a rheumatologic examination of Plaintiff and confirmed the diagnosis of fibromyalgia. (Id. at 209, 676.) Dr. Stanescu observed tenderness at all fibromyalgia tender points, but no swelling or tenderness in any of the joints. (Id.) Dr. Stanescu saw Plaintiff for a follow-up appointment on March 16, 2009, where Plaintiff reported that her musculoskeletal pain had improved and “she is doing better [overall].” (Id. at 215.) Plaintiff reported “she does not consider attending a pain clinic at this point, ” and Dr. Stanescu recommended “regular exercises, daily walking, and regular gentle stretching.” (Id.)

         On June 12, 2009, Plaintiff met with Dr. Muhammad Gul to establish a primary care relationship. Dr. Gul confirmed the diagnosis of fibromyalgia and recommended Plaintiff increase her physical activity to help control her pain. (Id. at 291-93.) Plaintiff admitted to both drug and alcohol use. (Id. at 292.) A laboratory report issued on June 23, 2009 was positive for amphetamines, benzodiazepines, opiates, and cannabis. (Id. at 218.) On July 21, 2009, Dr. S. Ram Upadhyay completed a Physical Residual Functional Capacity Assessment upon examination of Plaintiff’s file in which he confirmed a diagnosis of fibromyalgia and counseled limitation to light exertion, with occasional prolonged postures, and avoiding hazardous environments. (Id. at 297-304, 687.)

         On March 23, 2010, Plaintiff reported to Dr. Karen Kelly, who was treating Plaintiff for sinus complaints, a history of using drugs and alcohol since the age of seventeen. (Id. at 373.) On March 29, 2010, Plaintiff presented for intake at the On Call Urgent Care center for Suboxone treatment. (Id. at 467.) There, Plaintiff reported drug use since the age of nineteen and tested positive for marijuana, benzodiazepines, oxycodone, and buprenorphine. (Id.) During an April 12, 2010 appointment with Dr. Gul, Plaintiff reported she had no knowledge or explanation for why she had tested positive when asked about a prior toxicology screen that was positive for marijuana and Suboxone. (Id. at 375-77.)

         On June 2, 2010, Plaintiff was taken to Berkshire Medical Center by police due to apparent opiate overdose. (Id. at 608, 612.) A significant number of pills were found to be missing from Plaintiff’s prescription of Adderall and Soma, both of which were recently filled. (Id. at 612.) When questioned, Plaintiff denied intention of overdose. (Id.) The medical report stated that Plaintiff “told the admitting doctor in the emergency room that she gave some of her medications to a friend . . . but she told the admitting nurse that her medications were stolen from her.” (Id.) Plaintiff reported using drugs and alcohol since the age of fourteen and, at that point in time, using cannabinoids occasionally, the last occasion being Memorial Day 2010. (Id. at 613-14.)

         On June 17, 2010, Plaintiff underwent a consultative examination with Dr. Kautilya Puri, where Plaintiff reported a history of fibromyalgia, depression, anxiety, and ADHD. (Id. at 360-64.) Plaintiff reported that she can do some cooking, cleaning, laundry, and child care and can manage personal grooming. (Id.) Dr. Puri noted that Plaintiff could perform a full squat, used no assistive devices, required no assistance changing for the exam or getting on and off exam table, and “appeared to be in no acute distress.” (Id. at 361.) Dr. Puri reported that Plaintiff’s “hand and finger dexterity [were] intact” and she had no objective limitations to “fine motor or gross motor activity.” (Id. at 362.) Further, Dr. Puri reported that “there were no objective limitations to . . . [Plaintiff’s] activities of daily living.” (Id.) During that visit, Plaintiff denied use of alcohol or street drugs. (Id. at 360.) On a toxicology screen from a June 24, 2010 Suboxone treatment, Plaintiff tested positive for buprenorphine, benzodiazepines, and marijuana. (Id. at 492.)

         On October 8, 2010, Plaintiff established care with Joan McFadden, M.D. and reported worsened pain from her original fibromyalgia diagnosis. (Id. at 366.) On examination, Plaintiff presented with a normal affect and good eye contact, was well groomed, and appeared in no acute distress. (Id.) During an April 15, 2011 appointment, Dr. McFadden conducted a brief examination and noted that Plaintiff was in no acute distress and sat comfortably for the entire 25-minute encounter. (Id. at 886.) Dr. McFadden also noted that this was “somewhat in contrast to her reported ability to sit for no longer than five minutes at a time because of stiffness and discomfort.” (Id.) Dr. McFadden completed a Residual Functional Capacity Assessment on April 15, 2011, in which she found Plaintiff limited to less than sedentary exertion with the ability to sit or stand for 30 minutes at one time. (Id. at 649-53.) In an eight-hour working day, Dr. McFadden found Plaintiff able to sit for a total of three hours and stand or walk for a total of one hour with the need for walking breaks for a total of 30 minutes at five minute increments each break. (Id. at 651.) She also found Plaintiff could never lift over 20lbs and could rarely stoop, crouch or squat, climb ladders, or climb stairs. (Id. at 651-52.) Dr. McFadden estimated that Plaintiff would likely be absent from work as a result of her impairments more than four days per month. (Id. at 652.) She also characterized Plaintiff’s pain as occurring throughout Plaintiff’s body and “precipitated by heavy activity.” (Id. at 649.) Dr. McFadden noted in her treatment record from the April 15, 2011 appointment that her answers to the Residual Functional Capacity Assessment were “completed to the best of [her] ability” and that “these estimates are difficult to make.” (Id. at 886.)

         Plaintiff had follow-up appointments with Dr. McFadden on December 6, 2011 and February 10, 2012. (Id. at 878, 881.) On December 6, 2011, Plaintiff reported continued pain throughout her body and lower back, but refused further testing at the time due to scheduling conflicts. (Id. at 881.) Dr. McFadden noted Plaintiff appeared well developed and in “no acute distress.” (Id. at 882.) On February 10, 2012, Plaintiff reported continued pain in her lower back and that while her symptoms had improved somewhat after her last visit, they have since become “much worse.” (Id. at 878.) During this visit, Plaintiff denied drug use. (Id. ...

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