United States District Court, D. Massachusetts
MEMORANDUM OF DECISION ON PLAINTIFF'S MOTION TO
REVERSE THE DECISION OF THE SOCIAL SECURITY ADMINISTRATION
(DOCKET NO. 21) AND DEFENDANT'S MOTION TO AFFIRM THE
COMMISSIONER'S DECISION (DOCKET NO. 29)
Timothy S. Hillman United States District Judge.
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). For the reasons set forth below,
Defendant's motion is granted and
Plaintiff's motion is denied.
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.
filed her applications for DIB and SSI on March 18, 2009,
alleging onset of disability on July 31, 2005. (AR. 22, 76,
154-64). 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
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).
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. 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.
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.
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).
February 2006, Plaintiff's primary complaint was left jaw
pain, which Dr. Cohan thought was due to deteriorating left
lower molars. (AR. 253).
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).
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).
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.
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).
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.
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).
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).
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).
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).
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.
Assessments and Other Evaluations by Massachusetts Disability
Determination Services Physical RFC
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).
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).
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)
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.
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). ...