United States District Court, D. Massachusetts
MEMORANDUM AND ORDER
B. SARIS, CHIEF UNITED STATES DISTRICT JUDGE
Anna Fontes brings this action under 42 U.S.C. § 405(g)
for judicial review of a final decision denying her
application for Social Security Disability Insurance
(“SSDI”) benefits. Plaintiff suffers from various
physical and mental impairments including major depressive
disorder, anxiety disorder, panic disorder, cervical
occipital neuralgia,  history of chronic left chronic otitis
media,  and status post left
tympanoplasty. She argues that the Administrative Law
Judge's (“ALJ”) residual functional capacity
(“RFC”) findings were not supported by
reasons set forth below, the Court DENIES
Plaintiff's motion to reverse the Commissioner's
decision. (Docket No. 10) and ALLOWS
Defendant's motion to affirm the Commissioner's
decision (Docket No. 13).
Ana Fontes (“Plaintiff”) was 52 years old when
she filed her application for SSDI on March 19, 2018. R. 15,
50. She had previously worked as an industrial cleaner, cell
coordinator, and material handler. R. 65. Plaintiff alleged
disability due to major depressive disorder, anxiety
disorder, panic disorder, cervical occipital neuralgia,
history of chronic left chronic otitis media, and status post
left tympanoplasty. Docket No. 1 at 2.
alleged onset date of disability was December 14, 2017, the
date of her ear surgery. R. 15. Over the next year, Plaintiff
would receive medical care from the Massachusetts Eye and Ear
Infirmary, Hawthorn Medical Associates, and the Spaulding
December 22, 2017, Plaintiff had a post-surgery visit at the
Massachusetts Eye and Ear Infirmary. Care providers noted
that Plaintiff had a persistent earache, despite oral
antibiotics. Plaintiff stated that her hearing had gradually
worsened, and that she felt dizzy when bending over or
turning her head quickly. R. 399. On February 2, 2018,
Plaintiff attended a follow up visit at the same provider.
Notes from the appointment indicate that Plaintiff's
hearing had improved, but she was still bothered by
dizziness. R. 407. She was given a referral to
vestibular physical therapy. R. 409.
February 21, 2018, Plaintiff had an appointment at Hawthorn
Medical Associates. Documentation from Plaintiff's
appointment noted that she was having abdominal pain of an
unknown cause. R. 307.
March 22, 2018, Plaintiff went to Spaulding Rehabilitation
for an initial physical therapy evaluation. Plaintiff
reported a history of six surgeries related to her left
tympanic membrane.She described dizziness, headaches,
tinnitus, and imbalance triggered by looking down and
changing position. R. 606. She was enrolled in physical
therapy for six weeks. R. 608.
physical therapy session at Spaulding Rehabilitation on March
26, 2018, Plaintiff reported feeling unsafe on her feet due
to dizziness. R. 604. She also stated that her pain was
always at a five out of ten. Id. Finally, Plaintiff
reported that she had little to no tolerance to noise or
April 2, 2018, Plaintiff had a follow up appointment at
Massachusetts Eye and Ear Infirmary, where she stated that
she felt imbalanced when moving, could not dance, and
experienced tunnel vision when driving down long and straight
roads. R. 413. During her appointment, Plaintiff indicated
that she had not experienced any improvement after several
physical therapy sessions. Id. Upon examination, she
was noted to have normal speech and language function,
grossly normal memory and attention, and a very stiff neck
with difficulty turning her head. Plaintiff's gait and
balance were abnormal. R. 413-414. Plaintiff was referred for
vestibular testing. R. 413.
follow up at Spaulding Rehabilitation facility in April 2018,
Plaintiff noted no improvement to her symptoms. R. 602. She
continued to attend her physical therapy treatment sessions
over the following three months, but she reported continued
headaches, dizziness, and balance impairments during this
period. R. 582-602.
month later, on May 9, 2018, at her follow up appointment at
Hawthorn Medical Facility, Plaintiff noted sharp pains on the
right side of her head and requested a referral for a
neurologist. R. 571, 574. She was given the requested
referral, and was advised to quit smoking. R. 574-575.
19, 2018, Plaintiff had an ENT (ears, nose, and throat)
appointment at Southcoast Health. Documentation from her
appointment noted her left ear was “healing well,
” although she had continued trouble with balance. R.
621. Plaintiff's results were normal after table testing
and vestibular testing. The cause of her ongoing symptoms was
reportedly unknown. She reported difficulty in swallowing and
was strongly encouraged to quit smoking. R. 622.
attended physical therapy at Spaulding Rehabilitation on June
21, 2018. R. 585. Notes from the session indicate that the
Plaintiff had been “gardening and doing light duty yard
work for short periods.” R. 586.
on Plaintiff's self-assessment on July 11, 2018, her
physical therapist noted that she had not had any changes in
symptoms since starting physical therapy, and had experienced
ongoing headaches, dizziness, limited eye movement, balance
impairment, and pain. Her physical therapist also noted that
Plaintiff had little to no tolerance to noise and pressure
changes, and that she limited any strenuous activity.
Plaintiff was discharged with a home exercise program. R.
19, 2018, Plaintiff was examined by an ophthalmologist for a
routine eye exam. R. 613. She was noted to have 20/20 vision
with corrective lenses. R. 616.
26, 2018, Plaintiff went to Hawthorn Medical Associates for a
sick visit. Plaintiff was assessed with pharyngitis and
constipation, and was advised to use a saline spray and zinc
lozenges and to increase fluid intake. R. 541.
impacted ear wax was examined in a visit at Southcoast Health
on August 2, 2018. R. 629.
August 13, 2018, Plaintiff had a neurology appointment at
Hawthorn Medical Associates. R. 639. Plaintiff reported
numbness and tingling in her neck. R. 641. Her provider noted
that Plaintiff had significant occipital neuralgia, which can
cause fleeting head pains and intermittent blurry vision. R.
642. She was advised to massage, stretch, and use heat on her
neck. R. 642. The provider also referred Plaintiff for an MRI
of a benign cerebral tumor, which the provider explained was
not the cause of Plaintiff's head pains. R. 643. The
physician declined to prescribe muscle relaxers for the
Plaintiff's neck pain, because Plaintiff was drinking
four glasses of wine per night. R. 642. Documentation from
Plaintiff's August 13, 2018 appointment also noted that
Plaintiff had been smoking one and a half packs of cigarettes
per day. R. 642.
September 10, 2018, Plaintiff had a neurology appointment
with Dr. Conroy, in the neurology department of Hawthorn
Medical Associates. R. 634. Plaintiff complained of
significant neck pain and tinnitus. Dr. Conroy noted that
Plaintiff possibly had occipital neuralgia and “a lot
of psychosocial stress.” R. 637. Plaintiff was advised
that she would benefit from some therapy for her neck but was
reportedly resistant to this treatment. Id. Dr.
Conroy noted that Plaintiff had been prescribed a
“modest dose of Lexapro 5mg and [a] small dose of
Xanax” to take at bedtime. Plaintiff reported that she
was taking the Xanax three to four times per day. R. 637. Dr.
Conroy noted that the Xanax may have suppressed
Plaintiff's vestibular input. Plaintiff was reassured
that her benign cerebral tumor was stable and did not need to
be addressed at that time. R. 637.
October 12, 2018, Plaintiff went to the Massachusetts Eye and
Ear Infirmary. R. 645. She reported dizziness, headaches,
blurred vision, ear pain, and anxiety. Id. Results
from Plaintiff's ENG and rotational chair testing were
normal, and her MRI showed no interval growth. R. 646. She
was advised to follow up in one year. Id.
Psychiatric Treatment History
has met with Nurse Practitioner Claire Olivier once a week to
once every two months, depending on the severity of
Plaintiff's needs, since October 21, 2009. R. 529. Nurse
Practitioner Olivier offers individual psychotherapy and
medication management. Id.
February 21, 2018, Plaintiff had an appointment with Nurse
Practitioner Olivier. R. 449. She discussed her December 2017
ear surgery, which she felt was a “mess”.
Id. She also discussed feeling sadness related to
the recent loss of a friend. Id. Plaintiff expressed
fear that she would not be able to return to her job, which
required driving machinery. Id. Plaintiff also
mentioned tension at her workplace, explaining that it was no
longer a family-oriented place. Id. Nurse
Practitioner Olivier recorded that Plaintiff had good eye
contact, soft speech, goal-oriented thought processes, no
abnormal thought content, intact memory, intact attention,
and intact insight/judgement. R. ...