Scotia v. Colvin

          ORDER REGARDING PLAINTIFF’S SOCIAL SECURITY COMPLAINT

         I. INTRODUCTION

         Plaintiff Mona Lee Scotia (“Plaintiff”) seeks judicial review of the final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying her application for Supplemental Security Income (“SSI”) benefits pursuant to Title XVI of the Social Security Act. The matter is currently before the Court on the parties’ briefs, which were submitted without oral argument to the Honorable Erica P. Grosjean, United States Magistrate Judge.^[1] After a review of the administrative record, the Court finds the ALJ’s decision is proper and is supported by substantial evidence in the record as a whole. Accordingly, this Court affirms the agency’s determination to deny benefits and denies Plaintiff’s appeal.

         II. BACKGROUND AND PRIOR PROCEEDINGS

         Plaintiff filed an application for SSI on November 30, 2012, alleging a disability onset date of January 31, 2011. AR 25.^[2] Her application was denied initially on April 15, 2013 and on reconsideration on October 1, 2013. AR 92-95; 99-102. A hearing was conducted before Administrative Law Judge (“ALJ”) Thomas Cheffins on July 10, 2014. AR 40-65. On October 17, 2014, the ALJ issued a decision finding that Plaintiff was not disabled. AR 22-35. Plaintiff filed an appeal of the decision with the Appeals Council. AR 20. The Appeals Council denied her appeal, rendering the order the final decision of the Commissioner. AR 1-6.

         Plaintiff now challenges that decision, arguing that the ALJ’s decision is not based on substantial evidence in the record and that the ALJ erred when he found Plaintiff’s testimony not credible. (Doc. 18, pgs. 5-9). As a result of this error, Plaintiff argues that the Court should reverse the ALJ’s decision and remand the case to the Social Security Administration with instructions to award benefits. In opposition, Defendant argues that the ALJ’s adverse credibility findings are supported by substantial evidence. (Doc. 21, pgs. 4-8).

         A. Plaintiff’s Testimony

         Plaintiff was 59 years old at the time of the hearing. AR 45. Plaintiff is 5’6 ½” and weighs about 180 pounds. AR 47. She graduated college in 2010 and has a cosmetology license. AR 47. Plaintiff most recently worked as a hairdresser in 2010. AR 48. Plaintiff also worked briefly as a telemarketer. AR 50-51.

         Plaintiff testified that the pain in her lower back, neck, leg/knee, and feet limits her ability to work. AR 49-54. Plaintiff has received shots to alleviate the pain in her back and feet. AR 52-53. Plaintiff takes Vicodin when the pain is severe and Tramadol when the pain is moderate. AR 55. The medication makes Plaintiff dizzy. AR 55. Plaintiff uses a cane, although it was not prescribed by a doctor. AR 54-55.

         Plaintiff lives with her boyfriend. AR 46. Plaintiff reports that she has trouble standing, sitting, driving, and lifting objects. AR 54-55. Plaintiff reports spending most of the day lying down. AR 55. Plaintiff occasionally reads and uses a computer. AR 56. Plaintiff asserts that she is unable to do housework and that her boyfriend does all of the shopping and chores around the home. AR 55-56. Plaintiff does not drive, except for emergencies. AR 56.

         B. Medical Record

         The entire medical record was reviewed by the Court, however, only evidence that relates to the issues raised in this appeal is summarized below.

         i. Treating Physician - Thomas Mertins, M.D.

         Dr. Mertins has been Plaintiff’s primary care physician since 2010. AR 56-57. Dr. Mertins examined Plaintiff on July 2, 2014 and opined that Plaintiff’s chronic back and knee pain prevent her from being able to stand or sit for six to eight hours at a time.^[3] AR 310-11. Dr. Mertins noted that Plaintiff could stand for only ten minutes, walk for 100 feet without rest, and that Plaintiff’s impairments require her to lie down during the day. AR 312. Additionally, Dr. Mertins noted that Plaintiff was rarely able to reach up above her shoulders, down to her waist, or towards the floor. AR 312. Lastly, Dr. Mertins opined that Plaintiff was only able to lift and carry less than five pounds regularly. AR 312. Based on these findings, Dr. Mertins concluded that Plaintiff was unable to work. AR 313.

         X-rays of Plaintiff’s cervical spine, taken on June 25, 2014, showed a slight reversal of cervical lordosis centered at the C4 to C5 level, moderate narrowing of disc spaces at C3 to C4 and C6 to C7, and some facet arthropathy at C6 to C7. AR 331. An MRI scan, performed on July 14, 2014, showed multilevel degenerative disc disease, severe left-sided intervertebral neural foramina stenosis and impingement on the crossing left C4 nerve root at C3 to C4, mild to moderate right-sided intervertebral neural foramina stenosis, and moderate left-sided intervertebral neural foramina stenosis with probable impingement on the crossing left C7 nerve root at C6 to C7. AR 387-88.^[4]

         ii. Treating Physician - Mark Zachary, M.D.

         Plaintiff was examined by Dr. Zachary on November 14, 2012. AR 236. Dr. Zachary found that Plaintiff had a mild decrease in range of motion of the right knee with pain as well as crepitus and tenderness in the lateral aspect. AR 237. Dr. Zachary found Plaintiff’s right knee quadriceps strength to be decreased, but that she had an intact anterior cruciate ligament (“ACL”), as well as medial collateral ligament stability. AR 237. Plaintiff had no effusion, posterior knee swelling, calf tenderness, or distal edema. AR 237. Dr. Zachary diagnosed Plaintiff with right medial knee pain with lateral knee degenerative arthritis and lateral meniscal tear and obesity. AR 238. Dr. Zachary reviewed an MRI scan of Plaintiff’s right knee, performed on November 10, 2012, which showed advanced degenerative changes, displacement of the lateral meniscus from the joint line, and a complex tear and degeneration of the anterior horn of the lateral meniscus. AR 237; 280. Dr. Zachary found that Plaintiff’s symptoms did not seem to correspond with the MRI’s findings, and as such, Plaintiff was not a candidate for surgical intervention. AR 238. At the examination, Plaintiff denied experiencing paranoia, depression, anxiety or any sleep disturbances. AR 237.

         On February 7, 2013, Dr. Zachary noted that Plaintiff “continued to complain of pain on the medial aspect of the knee, although she is somewhat improved.” AR 296. Dr. Zachary opined that Plaintiff should “continue knee strengthening exercises” and “avoid aggravating factors.” AR 296. On May 29, 2013, Plaintiff presented as having recurring pain in her knee with difficulty walking. AR 290. Plaintiff denied any locking, catching, or giving way. AR 290. On April 10, 2013, Dr. Zachary recommended that Plaintiff continue with knee exercises and that if symptoms recurred, Plaintiff should consider Orthovisc injections. AR 294. On September 20, 2013, Dr. Zachary noted that Plaintiff’s symptoms in her knee were improving after receiving Orthovisc injections. AR 283. At the examination, Plaintiff stated that she felt her leg was getting stronger, and denied any locking, catching, or giving away. AR 283. However, on March 17, 2014, Dr. Zachary noted that Plaintiff continued to complain of severe pain in her knee and that prior steroid and Orthovisc injections were not providing her relief. AR 277. Dr. Zachary opined that Plaintiff's choices were to try additional steroid injections or proceed with arthroscopic surgery. AR 277. Dr. Zachary informed Plaintiff that there was no guarantee that arthroscopic surgery of her right knee would provide the pain relief she was looking for.^[5] AR 277. Dr. Zachary explained that Plaintiff had underlying severe arthritis and would eventually need a total knee arthroplasty. AR 277. Plaintiff did not elect to proceed with surgery, preferring instead to have a less invasive procedure. AR 277. On March 21, 2014, Dr. Zachary noted that an x-ray showed narrowing of the lateral joint line and osteophyte formation. AR 275. Dr. Zachary opined that Plaintiff was a candidate for partial knee replacement surgery of the lateral compartment. AR 275.

         iii. Treating Physician - Jonathan D. Carlson, M.D.

         Plaintiff visited Dr. Carlson on March 5, 2013, and again on September 6, 2013, to be evaluated for pain in her left side and back. AR 262-73. At both examinations, Dr. Carlson observed that Plaintiff had joint pain, stiffness, muscle weakness, joint swelling, back pain, muscle aches, and had experienced weight gain. AR 263; 270. Dr. Carlson noted that Plaintiff had focal tenderness at the bilateral lumbar paraspinous and pain with lumbar facet loading maneuvering. AR 264; 269. Dr. Carlson found Plaintiff to have normal tone and strength at her neck, spine, and upper and lower extremities. AR 264-65; 269-70. Dr. Carlson found Plaintiff’s gait and station to be normal and found that she could undergo exercise testing and participate in an exercise program. AR 264; 269. Dr. Carlson performed a mental status exam and determined that Plaintiff did not suffer from depression or anxiety. AR 265; 270.

         Plaintiff denied “tingling, numbness, or weakness” at the March 5, 2013 examination. AR 270. Dr. Carlson prescribed Plaintiff a trial period of tramadol. AR 270. An MRI, taken on September 4, 2013, showed severe disc desiccation, mild facet arthropathy, mild central canal stenosis, and moderate neural foramen narrowing at L2 to L3. AR 272. Plaintiff had a mild symmetrical disc bulge, facet arthropathy, and neural foramen narrowing at L3 to L4. AR 272. At L4 to L5, Plaintiff had severe facet arthropathy, moderate central canal stenosis, and left neural foramen narrowing. AR 272-73. At the September 6, 2013 examination, Dr. Carlson noted that Plaintiff stated that she “feels the pain medication regimen helps to improve activities of daily living.” AR 266. Dr. Carlson prescribed Plaintiff a trial period of ketoprofen, hydrocodone, and bilateral L3-S1 facet joint injections. AR 266. Additionally, Dr. Carlson noted a plan for Plaintiff to participate in a weight loss regimen and exercise therapy program. AR 266.

         iv. Examining Physician - Mark Dekutoski, M.D.

         Dr. Dekutoski met with Plaintiff on June 19, 2013 in regards to Plaintiff’s complaints of constant lower back pain. AR 255-61. Dr. Dekutoski observed that Plaintiff was in no obvious distress. AR 258. Dr. Dekutoski noted that Plaintiff was moderately obese, had a significantly deconditioned forward soft posture, and moved with a myofascial pain pattern. AR 258. Dr. Dekutoski found Plaintiff to have a limited range of motion of the lumbar spine, but noted that Plaintiff did not have pain with facet loading and had no issues with straight leg raises. AR 258-59. Dr. Dekutoski found Plaintiff to have full motor strength of the upper and lower extremities, and that Plaintiff had a normal range of motion of the thoracic and cervical spine. AR 259-60. Dr. Dekutoski noted that Plaintiff had a normal gait and station, ...