ERIC P. PSONAK, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
SHERRY R. FALLON, Magistrate Judge.
Plaintiff Eric P. Psonak ("Psonak" or "plaintiff') appeals from a decision of Carolyn W. Colvin, the Commissioner of the Social Security Administration ("Commissioner" or "defendant"),  denying his application for supplemental security income ("SSI") under Title XVI of the Social Security Act. The court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g).
Presently before the court are cross-motions for summary judgment filed by Psonak and the Commissioner. (D.I. 14, 17) Psonak asks the court to order an award of benefits, or, in the alternative, to remand this case for further administrative proceedings. (D.I. 14, 15) The Commissioner requests that the decision of the administrative law judge ("ALJ") be affirmed. (D.I. 17, 18) For the reasons set forth below, I recommend that the court deny Psonak's motion and grant the Commissioner's motion.
A. Procedural History
Psonak protectively applied for SSI on February 23, 2007, alleging disability beginning on September 15, 2006 due to a tumor in his neck and fibromyalgia in his right arm and neck. (D.I. 9, Tr. at 139, 163) Psonak's claim was denied initially on March 12, 2007, and upon reconsideration on November 1, 2007. ( Id. at 85-86) Psonak requested a hearing before an ALJ, which took place on January 8, 2009. ( Id. at 34, 97)
On April 29, 2009, the ALJ issued a decision confirming the denial of benefits. ( Id. at 15-33) Psonak requested a review of the ALI's decision by the Appeals Council on May 12, 2009, but the request for review was denied and, therefore, the ALI's decision became the final decision of the Commissioner subject to judicial review. ( Id. at 4-7, 10-11) On November 10, 2010, Psonak filed the current action for review of the final decision. (D.I. 1)
B. Factual Background
1. Medical History
Psonak began treating with Dr. James W. Sheehan on October 12, 2006 for pain, numbness, stiffness, and weakness in his head, neck, and spine. (D.I. 9, Tr. at 376-77) Dr. Sheehan described moderate limitation in Psonak's cervical range of motion and mild limitation in his lumbar range of motion, and cervical X-rays showed evidence of degeneration and cervical postural abnormality. ( Id. at 378-81) Dr. Sheehan recommended treatment with supervised electric stimulation spasm, mechanical traction, manipulation, manual therapy, and ultrasound. ( Id. at 382-83) Psonak returned to Dr. Sheehan on November 8, 2006, noting improvement in his neck and back pain and resolution of his muscle weakness and stiffness. ( Id. at 384) During this exam, Psonak exhibited only mild limitation in his cervical and lumbar range of motion. ( Id. at 387-89) Dr. Sheehan concluded that further treatment of the cervical and lumbar conditions, as well as lesions of the nerve roots, was not required because it was well-controlled. ( Id. at 390)
On November 23, 2006, Psonak was admitted to the inpatient psychiatric ward at Wilmington Hospital with suicidal ideation following a drunk driving accident. ( Id. at 244) He was diagnosed with substance-induced mood disorder, depression, chronic and musculoskeletal radicular pain, chronic low back pain, and hepatitis C. ( Id. at 245) He was prescribed Zoloft and Trazodone, and was stabilized with supportive medical and psychiatric interventions. ( Id. at 245-46) He was discharged on November 27, 2006 ( Id. at 246)
On November 26, 2006, Psonak visited Daniel 1. Elliott, M.D., for chronic lower back pain and right upper extremity pain. ( Id. at 251) Dr. Elliott observed that Psonak had multiple tumors on his forearms, upper arms, and legs. ( Id. at 252) Dr. Elliott diagnosed Psonak with radicular right arm pain and weakness, chronic lower lumbar spine pain, hepatitis C, anemia, thrombocytopenia, lipomas or neurofibromas, calvarial lesion, alcohol and psychiatric issues, and hyperglycemia. ( Id. at 253) Psonak underwent an MRI of his cervical and lumbar spine, which revealed lumbar and cervical radiculopathy. ( Id. at 278-81)
Psonak returned to Dr. Sheehan on November 30, 2006, having experienced a worsening of his previous conditions due to the November 23, 2006 automobile accident. ( Id. at 393) During a subsequent visit with Dr. Sheehan on December 20, 2006, Psonak reported that the treatment had improved his condition, and tests revealed only mild limitation in his cervical and lumbar range of motion, with a complete range of motion in his biceps, wrist, and triceps. ( Id. at 395, 401-02) Dr. Sheehan recommended manipulation, therapeutic exercises, and supervised electric stimulation to treat Psonak's conditions. ( Id. at 404-05)
On January 9, 2007, Psonak began treating with neurologist Enrica Arnaudo, M.D. for severe progressive right hand weakness and numbness. ( Id. at 885-89) Dr. Arnaudo noted severe right hand and forearm atrophy with numbness, and referred Psonak for an EMG/nerve conduction study of the right upper extremity. ( Id. at 888) Dr. Arnaudo observed that Psonak had symptoms consistent with entrapment neuropathies and recommended that he receive a neurosurgical consultation for cervical root or nerve decompression. ( Id. at 889) Psonak subsequently underwent an MRI of his right brachial plexus and cervical spine, which showed abnormal soft tissue on the right side of his thoracic spine, mild cervical degenerative disc disease, and multilevel cervical spondylosis with secondary foraminal stenosis. ( Id at 890-92)
On February 5, 2007, Psonak visited neurosurgeon Kennedy Yalamanchili, M.D., who conducted imaging studies and located a right-sided mass on his spine. ( Id. at 767) He concluded that Psonak suffered from multilevel cervical disk disease and significant nerve impingement, although there was no evidence of spinal cord compression. ( Id. at 769) Psonak underwent a biopsy of the soft tissue mass on his spine on February 9, 2007. ( Id. at 567) Imaging studies from February 21, 2007 showed foraminal tumors on his thoracic spine. ( Id. at 758) Dr. Yalamanchili diagnosed Psonak with neurofibromatosis and recommended surgical removal of two subcutaneous lesions in the thoracic region. ( Id. )
On March 22, 2007, Dr. Yalamanchili performed a laminectomy with foraminotomy, an instrumented fusion, and removal of a spinal mass. ( Id. at 462-504) Psonak returned to the hospital on March 29, 2007 with post-operative neck and chest pain and received Dilaudid. ( Id at 620) Psonak subsequently developed a thoracic wound infection and was admitted to the hospital from April 4, 2007 to April 10, 2007. ( Id at 505-12) Surgery was performed to achieve decompression of an abscess. ( Id. at 525-26) Psonak followed up with Wesley W. Emmons, III, M.D. for his wound infection on several occasions between May and August 2007. ( Id. at 574-77)
On May 2, 2007, Dr. Yalamanchili noted that Psonak's incision was healing well, the swelling was decreased, there was no discharge or tenderness at the incision site, and although he had decreased strength in his right upper extremity, the range of motion in his neck had improved and he had full range of motion in both shoulders. ( Id. at 755) X-rays of his thoracic spine showed appropriate bone growth and proper instrumentation placement with staple spinal alignment. ( Id. ) Dr. Yalamanchili gave Psonak permission to increase his activity level in moderation and recommended physical therapy. ( Id. ) Dr. Yalamanchili specifically noted that Psonak could return to work in a light duty supervisory capacity for the next six to eight weeks. ( Id. )
Psonak began visiting Adrienne N. Pinckney, MPT for physical therapy on May 10, 2007. (Id. at 692) Psonak presented with decreased myotomal strength in certain vertebrae, decreased cervical thoracic range of motion, and residual neural tension in his right upper extremity. ( Id. ) By June 6, 2007, Psonak presented asymptomatic in his neck and upper back. ( Id. at 691)
On May 14, 2007, Psonak visited Dr. Arnaudo, who noted severe impressive diffuse mass lesions with lipomas and neurofibromas throughout the arms, forearms, and thighs. ( Id. at 883) Psonak underwent surgery with Dr. Yalamanchili on November 26, 2007 to remove neurofibromas on his right upper extremity. ( Id. at 784) On December 19, 2007, Psonak underwent an MRI that revealed degenerative disc disease ranging from mild to severe throughout the cervical spine. ( Id. at 720) The MRI showed evidence of postoperative scar tissue, but no solid mass or abscess. ( Id. at 740) Dr. Yalamanchili performed surgery on January 14, 2008 to remove neurofibromas on Psonak's left upper extremity. ( Id. at 740)
Psonak began treating with orthopedist Evan H. Crain, M.D. on March 5, 2008 for pain in his left upper extremity. ( Id. at 733) Dr. Crain reported that Psonak had full painless range of motion in the neck, good shoulder range of motion, both active and passive, and his X-rays were normal, revealing no spur formation, joint space narrowing, or degenerative joint disease. ( Id. ) At Dr. Crain's suggestion, an EMG was performed on March 20, 2008, revealing mild, chronic left median entrapment neuropathy at the wrist consistent with mild to moderate carpal tunnel syndrome. ( Id. at 775) On March 31, 2008, Psonak noted improvement in his left shoulder since beginning treatment with Dr. Crain, although the right side had not improved. ( Id. at 732)
On June 16, 2008, after reviewing the results of Psonak's recent cervical MRI and thoracic spine X-rays, Dr. Yalamanchili concluded that no further surgeries were necessary to treat Psonak's spine and referred Psonak to a pain specialist. ( Id. at 739) On July 2, 2008, Psonak visited James E. Downing, M.D., a spine pain consultant, for neck and upper back pain. ( Id. at 796) Dr. Downing discussed a trial of lower cervical facet injections and physical therapy, but Psonak indicated that he did not have time to participate in physical therapy. ( Id. at 797) From September 17, 2008 to October 13, 2008, Psonak visited Julia Kegelman, D.P.T. of The Back Clinic, Inc. ( Id. at 798) Psonak made good progress with treatment and felt that he had more endurance for daily activities and reduced pain levels, but he was severely disabled according to the Oswestry Disability Index. ( Id. )
On October 30, 2008, E. Russell Ford, M.D., Psonak's family physician, completed a physical capacities evaluation of Psonak, opining that Psonak could sit for two to three hours without changing position if given a soft chair and a pillow, and he could stand and walk for fifteen to twenty minutes at a time. ( Id. at 806) Dr. Ford observed severe pain in Psonak's right upper extremity, hips, neck, upper and lower back, and legs, which was worsened by prolonged sitting standing, walking, and wet or cold weather. ( Id. ) Dr. Ford noted that Psonak had numbness, tingling, and weakness in his right upper extremity. ( Id. ) Dr. Ford opined that Psonak could lift and carry up to ten pounds occasionally, but could not push, pull, grasp, or perform fine manipulation with his right upper extremity. ( Id. at 807-08) According to Dr. Ford, Psonak could bend, squat, climb, reach above, stoop, and kneel only occasionally, and doing so would be very painful. ( Id. at 808) Moreover, he concluded that Psonak would need unscheduled interruptions of his work routine and would miss work frequently. ( Id. at 810) Dr. Ford opined that Psonak would not be able to work due to his chronic severe pain, stiffness, weakness, muscle spasms, numbness, burning and tingling. ( Id. at 811) Dr. Arnaudo completed an identical physical capacities evaluation on October 27, 2008. ( Id. at 870-75)
On November 14, 2008, Dr. Arnaudo diagnosed Psonak with neurofibromatosis, severe right hand weakness and numbness, and recent right foot drop. ( Id. at 877) Dr. Arnaudo indicated that the results of Psonak's November 19, 2008 EMG revealed subacute left peroneal entrapment neuropathy at the fibular head, which was consistent with his symptoms, clinical examination, and his recent improvement with physical therapy. ( Id. at 903-04)
2. The Administrative Hearing
a. Plaintiff's ...