United States District Court, D. Delaware
ADONIS I. GOINS, Plaintiff,
CAROLYN W. COLVIN, Commissioner, Social Security Administration, Defendant
Gary W. Lipkin, Esquire, of Duane Morris LLP, Wilmington, Delaware, Counsel for Plaintiff.
Charles M. Oberly III, Esquire, United States Attorney, District of Delaware, and Dina White Griffin, Esquire, Special Assistant United States Attorney, Office of the General Counsel, Social Security Administration, Philadelphia Pennsylvania. Of Eric P. Kressman, Esquire, Regional Chief Counsel, Region III and Katie M. Gaughan, Esquire, Assistant Regional Counsel, Office of General Counsel, Social Security Administration, Philadelphia, Pennsylvania, Counsel for Defendant.
Sue L. Robinson, District Judge.
Adonis I. Goins (" plaintiff) appeals from a decision of Carolyn W. Colvin, the Commissioner of Social Security (" defendant" ), denying his application for disability insurance benefits (" DIB" ) under Title II of the Social Security Act, 42 U.S.C. § § 401-434. (D.I. 1) Plaintiff has filed a motion for summary judgment asking the court to award DIB or remand for further proceedings. (D.I. 10,11) Defendant has filed a cross-motion for summary judgment, requesting the court to affirm her decision and enter judgment in her favor. (D.I. 13, 14) The court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g).
A. Procedural History
Plaintiff filed a protective claim for DIB on April 26, 2007, asserting disability (since the alleged onset date of October 15, 2006) due to back problems, migraines, sinusitis, depression and post-traumatic stress disorder (" PTSD" ). (D.I. 8 at 233-36, 282) His claim was denied initially and after reconsideration. ( Id. at 100-104, 108-113) Administrative Law Judge Melvin D. Benitz (" ALJ" ) held a hearing on May 21, 2009. ( Id. at 60-82) In a decision dated August 3, 2009, the ALJ found plaintiff not disabled. ( Id. 85-95) On August 17, 2009, plaintiff requested a review of the ALJ's decision by the Appeals Council. ( Id. at 146-47)
On April 14, 2010, the Appeals Council remanded the matter, finding, in part, that
the ALJ failed to provide an adequate evaluation of the medical source opinion evidence offered by Cyndia Choi, M.D. (" Dr. Choi" ), plaintiff's treating psychiatrist. ( Id. at 98) The Appeals Council directed the ALJ to consider the detailed medical opinions offered by Dr. Choi and to assess this information against pertinent Social Security Rulings. ( Id. at 98-99)
A hearing was held before the ALJ on January 4, 2011. ( Id. at 30-59) Plaintiff, represented by counsel, appeared and testified. ( Id. at 11) Vocational expert, Mitchell A. Schmidt (" VE" ), also testified.
In a decision dated February 4, 2011, the ALJ found that plaintiff was not disabled. ( Id. at 8-29) The Appeals Council denied review. ( Id. at 1-6) Having exhausted his administrative remedies, plaintiff filed a civil action on May 5, 2012, seeking review of the final decision. (D.I. 1)
B. Factual Background
1. Plaintiff's medical history, treatment and condition.
Plaintiff, born in 1970, was 36 years old at his alleged onset date. (D.I. 8 at 33, 233) Plaintiff is considered a younger individual under 20 C.F.R. 404.1563(c). He has a high school education and a vocational degree in pharmaceuticals. ( Id. at 33) Plaintiff's past relevant work was as a building maintenance manager, an air line baggage handler, park service worker, construction worker, and a dialysis technician. ( Id. at 53-54)
The record medical evidence reflects that in December 1998, plaintiff commenced treatment in the emergency room at the Philadelphia Veterans Affairs Medical Center (" VAMC" ), after having sustained an injury while lifting a heavy box. ( Id. at 443) Medical notes indicate that, due to a car accident in 1993, plaintiff suffered chronic low back pain, whiplash and neck pain. ( Id. at 443) As a result of the injury, he had increased pain in his back and neck. X-rays were negative. Plaintiff was advised to rest, avoid heavy lifting, and to use a heating pad. A follow-up appointment with the VAMC clinic was scheduled. ( Id. )
On February 21, 2002, plaintiff went to the Primary Care Center at the VAMC for his first appointment. ( Id. at 440) He was treated by Joan A. Gallo, CRNP (" Nurse Gallo" ). ( Id. at 441) Medical notes identify low back pain and migraines as his chief problems. ( Id. at 440) X-rays, anti-inflammatory medications and physical therapy were ordered. ( Id. at 441)
On April 23, 2002, plaintiff presented to the Mental Health Outpatient Clinic (" MHC" ), stating that he was " not sleeping and was never treated for PTSD." ( Id. at 437) Progress notes indicate that plaintiff was not having suicidal or homicidal ideation or hallucinations. His thought process was goal directed and he was alert, polite, oriented and cooperative during the examination. Plaintiff reported feeling easily agitated and having sleep disruptions (including nightmares) for some time. A PTSD evaluation was scheduled.
On the same day, plaintiff had an appointment with Nurse Gallo, complaining of persistent back pain. ( Id. at 438) A back x-ray revealed mild degenerative joint disease at L5-S1. ( Id. at 438, 431) Plaintiff reported that the pain medications he was taking were ineffective. ( Id. at 438)
Plaintiff returned for an appointment with Nurse Gallo on July 11, 2002 for complaints of back pain, arm numbness, and insomnia. ( Id. at 435) He was encouraged
to seek an evaluation for PTSD. ( Id. at 436)
On August 2, 2002, plaintiff had an evaluation with a physical therapist. ( Id. at 433) He tolerated the therapy well and was given back strengthening exercises to do at home. ( Id. at 434)
During a January 23, 2003 appointment at VMAC, plaintiff complained of chronic lower back pain and frequent migraine headaches. ( Id. at 430) Plaintiff said that Excedrin helped with headaches. He was referred to physical therapy and provided with back strengthening exercises. ( Id. at 431)
On July 28, 2003, plaintiff a had follow-up appointment with Nurse Gallo and complained of lower back pain and migraine headaches. ( Id. at 426) At that time, plaintiff was working for an airline performing a lot of physical labor. ( Id. at 427) Progress notes reflect that plaintiff was having difficulty coping with PTSD issues. ( Id. at 429) Nurse Gallo scheduled an appointment with the MHC.
On August 12, 2003, plaintiff returned to the MHC, complaining of back pain and nightmares. ( Id. at 420) Plaintiff relieved the nightmares by consuming excessive amounts of alcohol. Psychotherapy, " given [plaintiff's] significant stressors and history of violent impulses," was recommended. ( Id. at 423) Plaintiff agreed to schedule therapy after his " alcohol consumption ceased." ( Id. ) His diagnosis was night terrors, PTSD and alcohol dependency.
On September 8, 2003, plaintiff appeared for an appointment at the MHC. ( Id. at 418-419) He reported having mood swings, " frequent nightmares about combat," and feelings of isolation. Progress notes reveal that plaintiff had some symptoms of PTSD, but was able to tolerate without medication.
On November 6, 2003, plaintiff had a follow-up appointment with Nurse Gallo. ( Id. at 414) He indicated that he was happy to be working as a park service employee. Plaintiff complained of lower back pain, sleep problems and migraines. ( Id. at 415) Nurse Gallo requested input from the Psychiatry Department regarding PTSD.
On January 13, 2004, plaintiff was examined by Dr. Gabriel Bucurescu (" Dr. Bucurescu" ), a board certified neurologist, for migraine headaches that were occurring 5-6 days a week. ( Id. at 410) The throbbing pain plaintiff experienced was also accompanied by nausea. Dr. Bucurescu found that plaintiff was able to follow three step commands, repeat and name appropriately, and had normal writing and reading abilities. ( Id. at 411) He was prescribed Naproxen, Propranolol  and Excedrin. ( Id. at 413)
Plaintiff returned to Nurse Gallo on March 8, 2004, with complaints of lower back pain and migraine headaches. ( Id. at 406) His medications and x-rays were reviewed. ( Id. at 407)
On September 13, 2004, plaintiff was assessed a Global Assessment of Functioning (" GAF " ) score of 48. ( Id. at 381) A diagnosis of PTSD was also noted.
Plaintiff returned for follow-up care with Nurse Gallo on September 16, 2004. ( Id. at 402) His complaints were lower back pain, migraine headaches, PTSD and allergies. ( Id. at 403) Progress notes reveal that plaintiff stopped drinking alcohol in November 2003.
On November 18, 2004, plaintiff had a follow-up visit with Nurse Gallo. ( Id. at 402) He complained of the same problems as outlined in the September 16th visit.
Over one year later, on January 23, 2006, plaintiff returned to Nurse Gallo with complaints of severe headaches, chronic back pain, sleep disturbances, and PTSD problems (including flashbacks). ( Id. at 397) The screening for PTSD was positive. ( Id. at 398) Plaintiff was referred to the Behavioral Health Laboratory (" BHL" ).
Plaintiff appeared for an appointment with BHL on January 25, 2006. ( Id. at 393) Based on the symptoms presented, plaintiff was diagnosed with major depressive disorder, anxiety disorder, and PTSD. ( Id. at 393-394) With respect to PTSD, plaintiff reported having the following experiences: (1) avoidance of a traumatic event; (2) trouble with recall; (3) loss of interest; (4) feeling detached; (5) feeling numb; (6) trouble sleeping; (7) irritable; (8) difficulty concentrating; and (9) feeling nervous. ( Id. at 394) An appointment with a mental health care provider was scheduled. ( Id. at 393)
On February 23, 2006, plaintiff had a follow-up appointment with Nurse Gallo. ( Id. at 391) His chief complaints were back pain, sleep problems, PTSD, headaches and depression. ( Id. at 392) Plaintiff's medications were adjusted and appointments with MHC and neurology were recommended.
On March 6, 2006, plaintiff was examined by Dr. Bucurescu for migraine headaches that were occurring approximately three days a week. ( Id. at 387) The migraines were accompanied by throbbing pain, light and sound sensitivity, and nausea that lasted the entire day. He was prescribed Propranolol, Excedrin and a follow-up appointment was scheduled.
On March 16, 2006, plaintiff was evaluated by board certified psychiatrist Cyndia S. Choi, M.D. (" Dr. Choi" ). ( Id. at 381) Dr. Choi found that plaintiff met the " criteria for PTSD," as he was experiencing nightmares, insomnia, hyper vigilance, and irritability. ( Id. at 381) Dr. Choi noted that plaintiff wished to avoid medication that was too sedating and was concerned about taking too much time off from work for doctor appointments. His GAF score was 48. ( Id. at 377)
On May 8, 2006, Dr. Bururescu examined plaintiff for complaints of migraine headaches. ( Id. at 378) Dr. Bururescu increased plaintiff's dosage of Propranolol, recommended continuation of non-prescription pain medication, and ordered a follow-up appointment.
Later that day, plaintiff was examined by Dr. Choi. The mental status examination revealed that plaintiff was irritable and anxious, his thought processes goal oriented, and his judgment was adequate.
( Id. at 377) He had no suicidal thoughts or homicidal ideation. Dr. Choi prescribed Celexa  and supplied plaintiff with a letter of unemployability. ( Id. at 377-378)
On June 29, 2006, plaintiff was seen by Nurse Gallo, complaining of frequent migraines, severe back pain and sleep problems related to PTSD. ( Id. at 374-75) Plaintiff said Celexa improved his mood, but caused drowsiness. Nurse Gallo recommended continued mental health treatment with Dr. Choi.
On June 29, 2006, plaintiff had a follow-up mental health examination with Dr. Choi. ( Id. at 373-74) Dr. Choi found plaintiffs mood was " dysphoric due to chronic PTSD," his affect was polite and thought processes were " goal directed." There was no psychosis or suicidal or homicidal ideation. Plaintiff reported being concerned about losing his job. Dr. Choi prescribed a Seroquel  and discontinued Celexa. ( Id. at 374) Plaintiff's GAF score was 47.
Plaintiff returned to Dr. Choi on September 8, 2006. ( Id. at 369) The mental status examination revealed that his: (1) affect was polite and appropriate; (2) thought processes were goal directed; (3) insight and judgment were adequate; and (4) thoughts were not suicidal or homicidal. ( Id. at 369-70) Dr. Choi observed that plaintiff was having " great difficulty keeping his present job due to his service connected disabilities." ( Id. at 369) She also noted that he was " despondent due to his situation" but was " coping." ( Id. at 369-70) Plaintiff's GAF score was 47. ( Id. at 359)
On the same date, plaintiff was treated by Dr. Bucurescu for migraine headaches. ( Id. at 370) The mental examination revealed that he was oriented to time, place and person; his judgment was good and he could explain similarities and proverbs well. ( Id. at 371) Although Propranolol was initially effective, plaintiffs migraines had resumed in intensity and frequency. Dr. Bucurescu discontinued Propranolol and suggested using Excedrin, as needed. A four month follow-up appointment was scheduled. ( Id. at 373)
On December 21, 2006, plaintiff was treated by Nurse Gallo for left hip pain. ( Id. at 366-68) He reported taking Motrin daily for relief. Progress notes indicate that his headaches were occurring daily and spontaneously. Motrin and Excedrin relieved the pain, but left plaintiff feeling dizzy. Plaintiff reported having sleep difficulties as well as nightmares. The loss of nighttime sleep made plaintiff tired and unable to work during the day. He admitted having suicidal thoughts. ( Id. at 368) Plaintiff's physical examination revealed very tense muscles and trigger points, with limited flexion of knees. He was prescribed Naproxen and told to continue Excedrin. A six-week follow-up appointment was scheduled.
On February 1, 2007, plaintiff returned to Nurse Gallo, complaining of headaches and chronic lower back pain. ( Id. at 363) The migraines would start soon after he awoke at 4:00 or 4:30 a.m. and last for three to four hours. Excedrin would relieve the pain, but left plaintiff feeling hungover.
On February 5, 2007, plaintiff saw Dr. Bucurescu complaining of frequent migraines. ( Id. at 360) Progress notes reflect that the headaches were without aura
and still " occurring rather frequently." ( Id. at 362) Dr. Bucurescu prescribed Zomig  to take at the onset of a migraine.
During a February 7, 2007 appointment, Dr. Choi observed that plaintiff was alert and oriented without psychosis. ( Id. at 359) His mood was dysphoric, thought content clear, without suicidal or homicidal ideation. Plaintiff expressed concerns with his inability to maintain employment. Dr. Choi provided a letter to support plaintiff's unemployability. His GAF score was 47. ( Id. at 353)
On March 7, 2007, plaintiff appeared for an appointment with a physical therapist to address his complaints of increased pain and decreased function. ( Id. at 357-59) His pain level was recorded at 7 out of 10 (highest). Instruction on exercises to relieve pain was provided. Plaintiff was scheduled for a six-week physical therapy plan.
Plaintiff appeared for a follow-up mental health evaluation with Dr. Choi on March 15, 2007, where he complained of frequent nightmares. ( Id. at 353) Dr. Choi noted:
[Plaintiff] continues to suffer with significant PTSD which interferes with his nightly sleep. He has frequent insomnia. He has been unable to hold a job due to his PTSD, although he would prefer to work, he ...