United States District Court, D. Delaware
REPORT AND RECOMMENDATION
MARY PAT THYNGE, Magistrate Judge.
On August 26, 2013, plaintiff Rosely Altagracia Stokes ("plaintiff") filed this action against Carolyn W. Colvin, Acting Commissioner of Social Security ("defendant"). Plaintiff appeals defendant's decision denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act. Presently before the court are the parties' cross-motions for summary judgment. For the reasons set forth below, the court recommends plaintiff's motion for summary judgment be denied, and defendant's cross-motion for summary judgment be granted.
A. Procedural History
On November 9, 2009, plaintiff applied for DIB, and on November 27, 2009 she applied for SSI. In both applications, plaintiff alleged she was disabled starting on January 9, 2009, due to a heart condition, back problems, and numbness in her arm and back. Plaintiff's applications were initially denied on May 19, 2010 and on reconsideration on September 28, 2010. On November 10, 2010, plaintiff filed a written request for a hearing.
A hearing before Administrative Law Judge ("ALJ") Melvin D. Benitz was conducted on August 30, 2011. Plaintiff, represented by Tricia A. O'Donnell, a non-attorney representative, testified at the hearing. Christina Cody, an impartial vocational expert ("VE"), also appeared at the hearing. On October 19, 2011, the ALJ issued a written decision denying plaintiff's applications for DIB and SSI. The ALJ noted plaintiff's insured status expired on December 31, 2013, and therefore, she was required to establish disability on or before that date in order to be entitled to a period of disability and DIB. The ALJ held plaintiff was not disabled under sections 216(i), 223(d), and 1614(a)(3)(A) of the Social Security Act. Specifically, the ALJ found plaintiff had severe impairments, including depression, post-traumatic stress disorder, degenerative disc disease, chronic obstructive pulmonary disease, and coronary artery disease (aortic thoracoabdominal aneurysm), but nonetheless had the residual functional capacity to perform simple unskilled light work as defined in 20 C.F.R. § 404.1567(b) and § 416.967(b). The ALJ further determined although plaintiff could perform said work, she can sit for 20-30 minutes, stand for 20-30 minutes on an alternate basis during an eight hour workday with ordinary and customary breaks,  and avoid heights, dangerous machinery, climbing stairs, ropes, ladders, and odors, gases, fumes, and dust. He also found she could only have occasional interactions with her supervisor, the public and co-workers. The ALJ found plaintiff mildly limited in pushing and pulling with her lower left extremity.
Plaintiff's subsequent appeal to the Appeals Council was denied, as the Council concluded there was no basis for reviewing the ALJ's decision. The ALJ's decision, therefore, constitutes the final decision of the Commissioner.
Having exhausted all administrative remedies, plaintiff now seeks judicial review of this decision under 42 U.S.C. § 405(g). On January 16, 2014, plaintiff moved for summary judgment. On February 18, 2014, defendant filed a cross-motion for summary judgment.
B. Factual Background
Plaintiff was 45 years old at her onset date, and is considered a "younger person" at all times relevant to her DIB and SSI applications. She has a ninth-grade education. Her prior vocational experience included hand packager, machine operator, assembler, warehouse worker, and housekeeper.
1. Medical Evidence
Prior to the alleged onset date, plaintiff underwent open heart surgery for a thoracic aortic aneurysm with dissection, followed by intensive care for one month. On September 30, 2008, Madhavi Y. Yerneni, M.D. ("Dr. Yerneni"), a specialist in internal medicine, noted plaintiff had emphysema ("COPD"), which had been stable since 2006. On March 31, 2008, Dr. Yerneni diagnosed plaintiff suffered from depression, spondylosis/osteoarthritis of the spine, chest pain and had returned to smoking. On April 9, 2008, plaintiff reported thoracic back pain at a follow-up visit with Derreck Robinson, P.A. ("Robinson"), describing the pain as "needle-like" and worse when working. Robinson found tenderness on palpation of the thoracic spine regions, prescribed Tramadol, and advised to alternate positions at work.
On July 31, 2008, she returned to Dr. Yerneni complaining of significant left knee pain. Dr. Yerneni noted tenderness of the left knee, diagnosed bursitis and administered a Steagall injection. Plaintiff returned to Dr. Yerneni on August 28, 2008, because of severe abdominal pain after being diagnosed with diverticulitis at Rhode Island Hospital a week prior. Dr. Yerneni noted continued abdominal pain, which had improved. On September 19, 2008, plaintiff visited Dr. Yerneni reporting persistent burning and tingling thoracic pain, which was progressive and prevented standing or working. Dr. Yerneni diagnosed thoracic pain with paresthesias and a suspected herniated disk. Within six days, plaintiff was evaluated at the Rhode Island Hospital emergency room for shortness of breath and chest pain, radiating to her back. She described the pain at seven on a scale of one to ten. Thereafter, she was monitored and treated for several hours and released that night after the pain subsided. A thoracic spine MRI revealed degenerative changes at the L4-L5 level.
On February 4, 2009, plaintiff reported her back pain improved because she was no longer working. On August 11, 2009, plaintiff saw Dr. Yerneni, and advised she was doing well without chest pain or shortness of breath, but experienced episodes of vertigo. Dr. Yerneni recommended an evaluation by an ear, nose, and throat specialist.
On November 4, 2009, plaintiff was seen by Irene Szeto, M.D. ("Dr. Szeto") at Christiana Care Health Services ("Christiana"), for recurrent leg pain and dizziness. Dr. Szeto diagnosed hyperlipidemia and hypertension, prescribed Benazepril,  and referred plaintiff to Bhaskar Rao, M.D. ("Dr. Rao") for further evaluation of her vascular condition. On November 25, 2009, Dr. Rao reported plaintiff had lower left extremity pain and discomfort not associated with ambulation, which increased when walking long distances, and ordered a CT angiography. The CT angiography revealed a chronic type A aortic dissection, and he referred her to the Christiana emergency room for immediate evaluation by cardiac surgeons on December 16, 2009. The Christiana surgeons found plaintiff's condition was stable, and did not require any acute surgical intervention.
Plaintiff was evaluated by John Kelly III, M.D. ("Dr. Kelly"), a cardiologist, who noted chest discomfort, worsened by emotional stress, and prescribed a beta blocker. Dr. Kelly found no evidence of cardiac injury based on enzyme testing and an electrocardiogram, but recommended close follow up regarding her chronic thoracoabdominal aortic dissection.
On December 23, 2009, plaintiff was evaluated by an emergency room cardiac surgeon, who felt plaintiff's ascending aortic dissection was chronic in nature and could be managed medically with antihyperintensive agents. The same day, she saw Dr. Rao, who performed an exercise treadmill study, which revealed plaintiff was only able to ambulate for five minutes due to bilateral lower extremity pain. The study suggested the nature of her complaints of lower extremity pain were not arterial, but possibly neuromuscular. On January 22, 2010, plaintiff underwent a chest CTA which revealed an extensive post surgical repair of the ascending aortic dissection to the abdominal aortic bifurcation.
Plaintiff returned to Dr. Szeto for follow-up on February 23, 2010, reporting numbness and tingling in both hands at night and numbness and discomfort in her legs. Dr. Szeto's examination found her blood pressure was under "excellent control, " lungs clear to auscultation with non-labored respirations, normal heart rate and rhythm with no murmur, and normal gait, range of motion, and strength. Dr. Szeto continued the ACE-inhibitor for hypertension, determined plaintiff was currently disabled from work, and diagnosed "anti-dissection, carpal tunnel, restless legs, COPD, and hypertension."
On March 16, 2010, spirometry studies revealed no definite obstructive or restrictive ventilatory deficits, normal lung capacity, with mild reduction in vital capacity and moderate reduction in diffusion capacity. Plaintiff saw Dr. Szeto on April 6, 2010, and the findings reflected no focal neurologic deficits, normal gait, sensation, motor function, and strength. During the examination, plaintiff was cooperative, and her mood and affect were appropriate, with normal judgment and no suicidal ideation. Plaintiff advised Dr. Szeto of her appointment with Dr. Nguyen, a heart surgeon. Dr. Szeto noted "[i]t is unclear why she is going there, [plaintiff] is asymptomatic at this time."
On July 2, 2010, plaintiff complained to Dr. Szeto of shortness of breath, coughing, asthma, sleep apnea, difficulty balancing, memory loss, and depression. Dr. Szeto diagnosed depression, chest pain, hyperlipidemia, hypertension, asthma, sleep apnea, and emphysema and prescribed Prozac. Dr. Szeto further noted plaintiff's "general health status is good, " and she was engaging in "routine aerobic activity, 4-5 times a week" including bicycling, running, and weight lifting. On July 9, 2010, plaintiff underwent a sleep study which reveled no abnormalities.
Plaintiff returned to the emergency room on August 10, 2010 complaining of chest pain, shortness of breath, and palpitations. After blood work and a CT scan of the chest, she was discharged and instructed to follow-up with her treating cardiologist. On August 26, 2010, plaintiff underwent a CT scan of her head with normal findings. Plaintiff saw Dr. Szeto on November 10, 2010 and requested weight-loss medicine,  for which he prescribed phentermine, an appetite suppressant.
Plaintiff had a follow up appointment with Dr. Rao on March 16, 2011. He found no interscapular or back pain, and noted she continued her day-to-day activities without much difficulty. Dr. Rao ordered a repeat CT scan of the chest, and on April 6, 2011, he discussed surgical repair of her thoracoabdominal aneurysm. The CT scan confirmed a chronic dissection of the ascending aortic arch and the entire descending thoracic aorta, abdominal aorta and left iliac bifurcation, and a secular component in the mid thoracic aorta with a diameter of approximately 5.6 cm. Plaintiff desired surgery, and on October 6, 2011, Dr. Nguyen performed an aortic arch replacement procedure.
Plaintiff saw Dr. Kelly for an evaluation of her descending aortic dissection repair on October 24, 2011. Dr. Kelly noted plaintiff tolerated surgery and the stent procedure "reasonably well, " and diagnosed thoracic aortic dissection, chest pain, shortness of breath, hypertension, and obesity and advised her to progress with physical activities as tolerated.
On February 1, 2012, at Dr. Szeto's request, plaintiff underwent a CT scan of the lumbar spine to evaluate low back pain that radiated down her left leg, causing numbness and tingling. The scan revealed severe degenerative disk disease at L4-L5, with moderate size disk protrusion causing extradural impression on the spinal cord, as well as, narrowing of the lateral nerve root bilaterally and mild disk protrusion at L3-L4. Dr. Rao saw plaintiff on June 13, 2012 and concluded her lower extremity pain was unrelated to her aortic dissection and likely due to chronic lumbar degenerative disk disease, for which he referred her to a pain management specialist.
On June 20, 2011, Dr. Szeto checked a box on a form indicating plaintiff "is totally disabled without any consideration of any past or present drug and/or alcohol use." He checked the same box on an identical form on August 22, 2011.
On September 10, 2012, plaintiff was admitted to Christiana for another surgery, to repair the proximal thoracic aortic dissection. The primary diagnosis was proximal thoracic aortic dissection, with secondary diagnoses of hypertension, COPD, obesity, and depression. Plaintiff was discharged on September 14, 2012, with the following medications: Abilify, Atenolol, Simvastatin, Spiriva, and Trazodone.
2. Mental Health Medical Evidence
On November 30, 2010, plaintiff was admitted to MeadowWood, with symptoms of decreased concentration and memory, loss of energy and interest, poor hygiene, panic attacks, social withdrawal and isolation, generalized anxiety, and anger outbursts. Her diagnosis was major depressive disorder, recurrent, severe, with a GAF of 20. She was discharged on December 14, 2010.
On December 20, 2010, plaintiff was seen at Harmonious Mind Psychiatric and Counseling Services ("Harmonious Mind") for follow-up mental heath treatment complaining of chest tightness, fearfulness, visual hallucinations of shadows flying in the air, and audio hallucinations of "static-like" whispering. Kendall Dupree, M.D. ("Dr. Dupree") diagnosed plaintiff with major depressive disorder, single episode, severe without psychotic features, post-traumatic stress disorder ("PTSD"), and polysubstance dependence in sustained full remission and prescribed Trazodone, Pristig, and Risperdal. On January 27, 2011, plaintiff was discharged from Harmonious Mind for failing to attend scheduled appointments.
On January 31, 2011, plaintiff resumed treatment at Harmonious Mind, reporting her mood was improved and stable, with no thoughts of self-harm. Dr. Dupree diagnosed major depression, PTSD, and polysubstance abuse in full remission, and continued Pristiq and Trazodone.
On February 10, 2011, plaintiff reported that Pristiq helped; she had a brighter mood, more motivation, and no depression. On March 2, 2011, plaintiff complained of irritability for the previous week for unknown reasons, and weight gain from medications. Dr. Dupree prescribed Abilify and discontinued Risperdal.
Dr. Dupree completed a Psychiatric/Psychological Impairment Questionnaire on August 3, 2011, with diagnoses of bipolar disorder and PTSD, a GAF of 51 and fair prognosis. His clinical findings included sleep and mood disturbance, recurrent panic attacks, suicidal ideation or attempts, perceptual disturbances, decreased energy, generalized persistent anxiety, hostility, and irritability. He opined plaintiff's ability to maintain attention and concentration for extended periods, work in coordination with others, cooperation with co-workers or peers and avoiding or exhibiting behavioral extremes as markedly limited. He concluded her ability to understand, remember, carry out detailed instructions, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerance, accept instructions, respond appropriately to criticism from supervisors, maintain socially appropriate behavior, and adhere to basic standards of ...