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Martin v. Colvin

United States District Court, D. Massachusetts

August 3, 2016

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

         Cause: 42 U.S.C. § 1383 Review of HHS Decision

         Nature of Suit: 863 Social Security: DIWC/DIWW

          Michelle Elaine Martin, Plaintiff, represented by Tricia M. Jacobs, Law Offices of Thomas Libbos.

          Carolyn W. Colvin, Defendant, represented by Michael P. Sady, United States Attorney's Office.

          Social Security Administration, Interested Party, represented by Thomas D. Ramsey, Office of the General Counsel.


          DAVID H. HENNESSY, Magistrate Judge.

         The Plaintiff, Michelle Elaine Martin, seeks reversal of the decision by the Defendant, the Commissioner of the Social Security Administration ("the Commissioner"), denying her Disability Insurance Benefits ("DIB"), or, in the alternative, remand to the Administrative Law Judge ("ALJ"). (Docket #12). The Commissioner seeks an order affirming her decision. (Docket #14).

         By Order of Reference dated May 13, 2016, pursuant to 28 U.S.C. § 636(b)(1)(B) (Docket #19), 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 Martin's Motion to Reverse (Docket #12) be DENIED and Defendant's Motion for Order Affirming the Decision of the Commissioner (Docket #14) be ALLOWED.

         I. BACKGROUND

         A. Procedural History

         Martin filed an application for DIB on June 22, 2012, alleging that she had been disabled since August 21, 2010. (Tr. 172-78). The application was denied initially and on reconsideration. (Tr. 98, 114). Following a March 25, 2014 hearing, the ALJ rendered a decision unfavorable to Martin on March 26, 2014, finding that Martin had not been disabled from August 21, 2010, through the date of the decision. (Tr. 17-26).

         On July 21, 2015, the Appeals Council denied Martin's request for administrative review, making the ALJ's decision final and ripe for judicial review. (Tr. 1-6). Having timely pursued and exhausted her administrative remedies before the Commissioner, Martin filed a complaint in this Court on September 9, 2015, pursuant to 42 U.S.C. § 405(g). (Docket #1). Martin filed the motion for reversal or remand on January 13, 2016, (Docket #12), and the Commissioner filed a cross-motion on February 23, 2016, (Docket #14).

         B. Personal History

         At the time she claims she became disabled, Martin was forty-one years old. (Tr. 34). Martin has an associate's degree from Newbury College. (Tr. 41-42). She last worked in 2010 as a respiratory therapist at Harrington Regional Hospital, where she had been employed for approximately ten years. (Tr. 40-41). Martin is married and lives with her husband, Chris Martin. (Tr. 38). They do not have children. (Id.).

         C. Medical History

         On December 21, 2009, Martin was seen at UMass Memorial Hospital for complaints of vertigo, pain, and numbness (Tr. 547-51). She told hospital staff she had been previously diagnosed with Menière's disease and that she had experienced eight episodes of vertigo in eight days. (Tr. 547). She appeared normal upon examination. (Tr. 547-48).

         On January 19, 2010, Martin reported to her primary care physician, Dr. Kenneth Guarnieri, M.D., experiencing daily light-headedness, but claimed to have experienced no vertigo in the prior three weeks. (Tr. 392). In February 2010, neurologist Dr. Johnny Salameh, M.D. observed that Martin's neurologic functioning, muscle strength and tone, reflexes, cerebellar functioning, sensation, and gait were all normal. (Tr. 478-81). An EEG performed in May 2010 revealed "left temporal polymorphic theta range slowing, " which the reviewing physician noted was "consistent with a partial seizure disorder but not diagnostic of it." (Tr. 559-60). After a follow-up appointment in June 2010, Dr. Salameh largely echoed his February observations. (Tr. 475-77). He added that Martin "denied any loss of consciousness" during her episodes of vertigo and experienced "no double vision, no headaches, no nausea, no vomiting, no hearing problems as well as no pain, numbness or tingling sensation." (Tr. 476). Dr. Salameh continued Martin on Topomax, which had reduced the frequency of her dizzy spells. (Tr. 475).

         Martin underwent a three-day study in July 2010 to determine the cause of her frequent episodes of dizziness and vertigo. (Tr. 696-98). During the study, an EEG was performed during Martin's waking and sleeping hours. (Tr. 697). On the third day of the examination, Martin reported an episode of vertigo while playing a videogame. (Tr. 696). The episode lasted ten to fifteen seconds. (Id.). Martin remained standing and did not report any disorientation or confusion during the episode. (Id.). The examining neurologist, Dr. Jayant Phadke, M.D., reported that the results of an EEG during the episode were "completely normal" and that Martin's subjective symptoms were likely the results of a panic episode and not an "ictal process."[1] (Id.).

         In September 2010, neurologist Dr. Nabil Ahmad, M.D. examined Martin and noted she had intact strength and muscle tone, intact sensation, 2-3 reflexes with downgoing toes, intact coordination, and a normal gait. (Tr. 566-68). Dr. Ahmad noted that the cause of Martin's vertigo episodes remained unclear, but her vertigo was unlikely the result of complex partial seizures. (Tr. 567). Neurologist Dr. Catherine Phillips, M.D. also examined Martin and noted "she is doing better now that she is no longer at work." (Tr. 567-68).

         In February 2011, Dr. Fred Arrigg, Jr., M.D. attributed Martin's episodes of vertigo and dizziness to Martin's prior diagnosis of Menière's disease and history of migraines. (Tr. 288-89). Dr. Arrigg noted a "marked improvement" since Martin started taking Topamax and Zonisamide to treat her migraines. (Id.).

         On February 4, 2011, ophthalmologist Dr. Hugh Cooper, M.D. reported that Martin had suffered a "mini stroke" in 2008 which "resulted in left sided weakness and loss of vision in her left eye, which reportedly returned to normal." (Tr. 286). Dr. Cooper noted that a full work-up at the time was negative, but Martin reported "persistent intermittent episodes of vertigo, which occur sporadically lasting one to two minutes and resolve spontaneously." (Id.). He noted that Martin's vertigo had "improved on medication" and found no visual impairments. (Tr. 287).

         In April 2011, Martin presented at the emergency room of Harrington Memorial Hospital after a reported episode of vertigo. (Tr. 301-02). An examination returned normal results, with intact orientation, mentation, cerebellar function, motor skills, and sensation. (Tr. 302). The examining physician noted that Martin was "in no distress." (Id.). Her gait was steady, at a normal pace, and without difficulty. (Id.).

         In August 2011, after complaining of abdominal pain and bloating, Martin was seen by gastroenterologist Dr. Madan Zutshi, M.D. (Tr. 359). Dr. Zutshi found her symptoms to suggest Irritable Bowel Syndrome. (Id.). Dr. Dean Rodman, M.D. performed a CT scan of Martin's abdomen and pelvis with unremarkable results. (Tr. 292).

         In November 2011, Martin complained to Dr. Guarnieri of left hip pain. (Tr. 351). Upon examination, her hip was mildly tender to palpation. (Tr. 352). Dr. Marc Camacho, M.D. conducted an x-ray on November 15, 2011 with unremarkable results. (Tr. 290-91).

         In February 2012, Martin told Dr. Guarnieri she was feeling better after receiving steroid injections to treat her hip pain. (Tr. 348). Martin reported recurrent episodes of vertigo, back pain, shortness of breath, and elevated heart rate when climbing stairs. (Id.). She appeared normal upon examination. (Tr. 349). Dr. Guarnieri referred Martin to cardiologist Dr. Sheena Sharma, M.D., who performed an echocardiogram on March 5, 2012. (Tr. 619). Dr. Sharma stated that "subtle abnormalities cannot be excluded due to poor image quality, " but reported no significant abnormalities. (Id.). In a follow-up examination one week later, Dr. Sharma categorized the results as "normal." (Tr. 347). She noted that Martin was "moderately overweight, " but in "no frank distress." (Id.). Later that month, Dr. Sharma administered a cardiovascular stress test using a treadmill, which returned "[o]verall normal" results. (Tr. 344).

         On February 12, 2012, Dr. John R. Knorr, D.O. performed an MRI on Martin's lumbar spine which showed "[n]o focal lumbar disc abnormality." (Tr. 413-14). On February 13, 2012, neurologist Dr. Gary Keilson, M.D. examined Martin regarding her vertigo symptoms. (Tr. 442). Dr. Keilson noted that Martin had stopped taking Topamax, claiming it caused reflux. (Id.). Martin also reported that her prescription for Zonegran "only helped a little bit." (Id.). Dr. Keilson noted that studies of Martin's brain, cervical spine, and thoracic spine were all unremarkable and that Martin's sleep apnea responded to CPAP treatment. (Tr. 443). Upon examination, he found Martin's motor functioning, strength, coordination, reflexes, and sensation to be normal. (Id.). Martin's gait was mildly broad-based, but not ataxic. (Id.). In a follow-up examination conducted three months later, Dr. Keilson noted that the cause of Martin's vertiginous episodes remained unclear. (Tr. 500). Dr. Keilson opined that Martin "had extensive workup in the past, has seen neurologist [sic] in the past, she has had EEGs and brain scanning and this has all been unrevealing." (Tr. 499).

         In May 2012, Martin received an annual physical examination from Dr. Guarnieri. (Tr. 340-43). Martin reported abdominal pain, but denied feeling any other pain, dizziness, weakness, numbness, or symptoms of anxiety or depression. (Tr. 340-41). On physical examination, Martin's cranial nerves, deep-tendon reflexes, motor strength, and sensation were all normal. (Tr. 341-42). Dr. Guarnieri advised Martin to eat five to six servings of fruits and vegetables and to exercise at least thirty minutes per day on a regular basis. (Tr. 343).

         In July 2012, endocrinologist Dr. Richard Haas, M.D. examined Martin regarding thyroid nodules. (Tr. 485). Dr. Haas reported that Martin's thyroid nodules were the result of a "benign multinodular goiter." (Id.). He noted that the nodules had decreased in size during the prior two years and reassured Martin that the diagnosis was benign. (Id.)

         Martin saw Dr. Guarnieri for a follow-up examination in November 2012. (Tr. 609-10). Martin denied experiencing any pain, dizziness, weakness, numbness, or symptoms of anxiety or depression. (Id.).

         In December 2012, Martin received a consultative psychological examination with Dr. David Nowell, Ph.D. (Tr. 492-98). Martin reported she was not currently receiving any mental health treatment. (Tr. 492). Dr. Nowell noted that Martin had renewed her driver's license and was able to drive, though did so infrequently. (Tr. 493). Dr. Nowell noted that Martin managed her finances, but "prefer[red] to have her husband review the details." (Id.) Additionally, Martin reported that she could shop for groceries independently, but preferred her husband's company. (Id.). Her daily routine included feeding animals, watching television, working on the computer, preparing breakfast, and going to doctors' appointments. (Id.).

         Dr. Nowell diagnosed Martin with PTSD and mild depression but reported that Martin "appears to function in the high average range of general ability." (Tr. 494, 497). Additionally, he observed that Martin's speech and motor functioning were normal. (Tr. 494). Martin achieved a 30 out of 30 on a Mini Mental Status Examination. (Tr. 495). Dr. Nowell tested Martin's memory and attention/concentration and her performance fell "in the superior range, well above average for her age." (Tr. 497). Her performance was within normal limits for tests measuring her visual perception, scanning, and sequencing. (Tr. 496-97). Dr. Nowell surmised that Martin appeared capable of learning new information, "manag[ing] simple to moderate attention/concentration tasks, " and accepting supervision. (Tr. 498). Dr. Nowell opined that Martin's overall performance might be "below her premorbid best" but "cannot be described as impaired." (Tr. 497).

         In February 2013, Martin was seen again by Dr. Guarnieri. (Tr. 606-08). Martin once again denied feeling pain, dizziness, ...

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