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Johnson v. Colvin

United States District Court, D. Massachusetts

September 6, 2016

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


          Timothy S. Hillman United States District Judge.

         This is an action for judicial review of a final decision by the Commissioner of the Social Security Administration (the “Commissioner” or “SSA”) denying the application of Caitlyn Johnson (“Plaintiff”) for Social Security Disability Insurance Benefits and Supplemental Security Income. Plaintiff filed a motion seeking an order reversing the decision of the Commissioner (Docket No. 21), and the Commissioner filed a cross-motion seeking an order affirming the decision of the Commissioner (Docket No. 29).[1] For the reasons set forth below, Defendant's motion is granted and Plaintiff's motion is denied.

         Factual Background

         For purposes of SSI disability, a claimant must show that she had a disability which started before or during the period between the date of her SSI application (March 18, 2009) and the date of the ALJ's decision (October 27, 2011), and which lasted or was likely to last at least twelve months. 20 C.F.R. §§ 416.202, 416.305, 416.330, 416.335.

         Procedural History

         Plaintiff filed her applications for DIB and SSI on March 18, 2009, alleging onset of disability on July 31, 2005. (AR. 22, 76, 154-64).[2] After her applications were denied initially (AR. 82-87) and on reconsideration (AR. 89-94), Plaintiff requested an administrative hearing. (AR. 95). The hearing was held in September 2011 before Administrative Law Judge (“ALJ”) Judith Stolfo. (AR. 34-75). The ALJ heard testimony from the Plaintiff, who was represented by counsel, and from vocational expert Elaine Cogliano. (AR. 34). On October 27, 2011, the ALJ issued a decision finding Plaintiff not disabled. (AR. 19-33). On November 2, 2012, the Appeals Council denied Plaintiff's request for review, thereby making the ALJ's decision the final decision of the Commissioner. (AR. 2-9). Plaintiff timely filed this appeal.

         Medical Evidence

         In January 2005, Plaintiff was seen by her primary care physician, Kathryn Cohan, M.D., for complaints of low back and knee pain and frequent urination. (AR. 277). In March 2005, she also complained of anxiety and depression, episodes of altered consciousness (which did not appear to be actual syncope or a grand mal seizure), and nosebleeds (probably due to sinusitis). (AR. 273-74). In June 2005, Plaintiff told Dr. Cohan that she had experienced an episode of wooziness when helping her father work on a boat. (AR. 269). Dr. Cohan noted that Plaintiff did not appear anxious or agitated. Id. Dr. Cohan indicated that a cardiac workup had been negative and that another doctor was currently assessing the possibility of a seizure disorder. Id. Dr. Cohan observed that Plaintiff habitually ate poorly, relying mostly on sugary foods, and that Plaintiff routinely resisted all suggestions regarding improvement of her diet, claiming that her daughter was allergic to all the recommended foods. Id. Plaintiff also claimed that her daughter got into cabinets and the refrigerator, even if these were locked. Id. Dr. Cohan made additional recommendations (taking into account Plaintiff's lack of upper teeth) and suggested that she see a dietician, a suggestion which also was declined. (AR. 270).

         In June 2005, neurologist Dawn Pearson, M.D. noted that a brain MRI scan in May had been normal. (AR. 333). A Holter monitor had shown rare ventricular premature contractions, not associated with any symptoms. Id. Dr. Pearson felt that Plaintiff's near black-out episodes and headaches were probably due to dehydration and most likely hypoglycemia. Id. She ate rarely, but drank coffee and soda “essentially all day.” Id. Her symptoms were complicated by irritable bowel issues and her inability to afford dentures. Id. In September 2005, Dr. Cohan noted that Plaintiff's osteopenia (lower than normal bone density) could be due to her use of Depo-Provera (birth control by injection) or due to a diet poor in calcium and vitamin and her lack of regular exercise. (AR. 266). Dr. Cohan felt that Plaintiff's intermittent neurologic deficits might be due to a “migraine equivalent, ” possibly triggered by her use of birth control pills. Id. She was being seen by another doctor for her neck and back pain complaints. (AR. 267). At the end of the visit, Plaintiff asked Dr. Cohan to provide a note limiting her work activities, and Dr. Cohan agreed to write a note limiting her to no more than 30 hours a week.[3] At the time, Plaintiff was employed folding paper at a company called Jenson and Chase. (AR. 266-67). Dr. Cohan urged Plaintiff to begin using at least some of the recommended treatments, in particular physical therapy. (AR. 267). Later that month, Dr. Cohan noted that Plaintiff still had not begun taking any of the medications recommended for pain control because she wanted her psychiatric medications to be stabilized first, and she had not begun physical therapy due to scheduling conflicts. (AR. 263). Dr. Cohan felt that Plaintiff's mechanical back pain was the most likely cause of her symptoms, and that this could be aggravated by her work, which involved bending over an assembly line. Id.

         At the end of September 2005, Plaintiff told Dr. Cohan that she had not yet begun physical therapy. Dr. Cohan re-emphasized the need for this (and for follow-up with Plaintiff's physiatrist, Lorraine Gomba, M.D.). Id. Plaintiff had begun using the prescribed medications for muscle relaxation and pain relief, and was disconcerted that the area of her pain could shift from day to day. Id. Dr. Cohan advised her that this is typical of pain caused by muscle spasms rather than bulging disks. Id. Plaintiff's work put her at risk for spasms due to the amount of bending required, but her employer had no jobs available that could accommodate her problem. Id.

         In October 2005, Plaintiff was seen by Dr. Cohan for fever, malaise, and abdominal pain. (AR. 258). In November 2005, Plaintiff reported brief, intermittent coughing, which Dr. Cohan felt was due to a virus. (AR. 256). That same month, Dr. Gomba noted that MRIs showed disc bulging at ¶ 4-5 and L5-S1; there was a potential for some nerve impingement at ¶ 4-5. (AR. 323).

         In February 2006, Plaintiff's primary complaint was left jaw pain, which Dr. Cohan thought was due to deteriorating left lower molars. (AR. 253).

         In June 2006, Plaintiff was seen by orthopedist Richard Mulroy, M.D. in connection with her complaint of left knee instability. (AR. 320). On examination, Dr. Mulroy saw no sign of ligamentous instability or swelling; range of knee motion was normal. (AR. 321).

         In July 2006, Plaintiff was seen at Milford Regional Medical Center (“Milford”) in connection with imminent childbirth. (AR. 304-05). In August 2006, she was seen at Milford for abdominal pain. (AR. 299). Later that month, she told Dr. Cohan that she had some abdominal and lower back pain. (AR. 359). In December 2006, Plaintiff was seen at Milford for right ankle pain, following her fall down a few steps while carrying a box. (AR. 297). That same month, she had gallbladder removal surgery. (AR. 322).

         In January 2007, Plaintiff reported that she had recently re-injured her back while trying to prevent the fall of her father, who weighed 300 pounds. (AR. 358). Dr. Cohan noted that practical difficulties made it hard for Plaintiff to get physical therapy for her back pain on a regular basis. (AR. 357). Plaintiff had bronchitis, which appeared to be due to a bacterial infection. Id.

         In February 2007, Dr. Cohan noted that Plaintiff still was suffering from sinusitis, and prescribed a different antibiotic. (AR. 351). Plaintiff also expressed an interest in smoking cessation treatment. Id. In March 2007, Plaintiff was seen at Milford for complaints of nausea, vomiting, and diarrhea. (AR. 293). It was noted that she was pregnant. Id. She reported no anxiety or depression, and her mental status was normal. (AR. 293-94).

         In April 2007, Plaintiff was seen at Milford for abdominal cramping, nausea, diarrhea, and leg numbness. (AR. 290). Her only medication was Tizanidine, a muscle relaxant. (AR. 291). She had no psychological complaints. Id. A week later, she returned, reporting continued symptoms. (AR. 286). Plaintiff apparently underwent a tubal ligation in July 2007. (AR. 283).

         In August 2007, Plaintiff was seen at Milford for slurred speech. (AR. 283). She stated that she had first begun having episodes of slurred speech a year previously, after the birth of her child. Id. This problem was not associated with arm or leg weakness, facial drooping, or headaches. Id. Musculoskeletal and neurological findings were normal. (AR. 284). An EKG in September 2007 showed mild tricuspid regurgitation and a small pericardial effusion, but no sign of atherosclerotic disease or an unclosed atrial septum. (AR. 562).

         In October 2007, Plaintiff was seen at Milford for left lower back pain that had begun suddenly, two days previously. (AR. 279). At its worst, the pain level had been moderate, but currently it was mild. Id. Plaintiff said she had a one-year old child and did a lot of lifting. Id. She was using no medications. Id. On examination, Plaintiff showed limited range of spinal motion and lower back tenderness; neurological and psychiatric findings were normal. (AR. 281).

         In November 2007, Plaintiff told Dr. Cohan that she felt run down and needed to urinate frequently. (AR. 251). She continued to have low back pain, which had radiated into her right leg on two occasions. Id. Plaintiff said she had gotten very depressed during her last menstrual period. Id. Plaintiff did not appear to have a urinary infection and blood sugar testing did not indicate likely diabetes. (AR. 252). Later that month, Dr. Cohan treated Plaintiff for bronchitis and pharyngitis. (AR. 250).

         In December 2007, Plaintiff was seen by Joseph Wilson, M.D. for neck contusions due to an assault by Plaintiff's boyfriend. (AR. 245). That same month Dr. Cohan treated Plaintiff for a continuing episode of either bronchitis or smoldering sinusitis, (AR. 243-44).

         In January 2010, Dr. Cohan reported that Plaintiff could not perform even sedentary work on a sustained basis, and had been unable to do such work since at least November 2004. (AR. 649-51).

         RFC Assessments and Other Evaluations by Massachusetts Disability Determination Services Physical RFC

         In November 2009, S. Ram Upadhyay, M.D. reviewed Plaintiff's records and concluded that, for the period up through September 30, 2006, when Plaintiff's insured status expired for purposes of DIB (but not SSI) eligibility (AR. 24), she remained able to do light work, subject to limitations in climbing ladders, stooping, crawling, and working around hazards. (AR. 608-14).

         In April and May 2010, J. Quinlan, M.D. and C. Jones, M.D. reviewed records relating to Plaintiff's physical condition and concurred with Dr. Upadhyay's assessment. (AR. 638; 639-44).

         Mental RFC

         In December 2009, psychologist Lawrence Langer, Ph.D. reviewed Plaintiff's mental health records and concluded that she could understand and remember short and simple instructions; she could carry out simple, one- to two-step instructions; she could maintain attention for two-hour periods; she could complete a normal work week at a sufficient pace; she could be socially appropriate; and she could adapt to minor changes in her work setting. (AR. 616-18, 632). In April 2010, psychologist John Garrison, Ph.D. reviewed the updated record and concurred with Dr. Langer's assessment. (AR. 637)

         Dr. Kathryn Cohan, MD, Plaintiff's primary care physician, provided a residual functional capacity having a date of March 21, 2011. (AR. 1081-1083). She diagnosed back pain, depression and osteopenia. Id. Plaintiff was limited to standing no more than 10 minutes. She could sit for 50 minutes at a time. Plaintiff would be absent more than four times a month because of her disability. (AR. 1082). Plaintiff was not a malingerer. Plaintiff could not lift and carry 10 lbs. in a competitive work environment. Id.

         Dr. S. Ram Upadhyay provided a physical residual functional capacity assessment on November 16, 2009, at the request of the agency. (AR. 608-619). He noted a history of MVP and fluid around the heart in the past and echo heart testing. (AR. 609). He confirmed there was an MRI in 2004 showing disc protrusion at ¶ 4-5. His report provides, “Credibility partial.” (AR. 609). ...

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