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Salmons v. Astrue

United States District Court, D. Delaware

March 2, 2015

MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.


GREGORY M. SLEET, District Judge.


On September 23, 2010, the plaintiff, Harold D. Salmons ("Salmons"), filed this action against the Defendant Michael J. Astrue, Commissioner of Social Security, [1] for review of the final decision denying him Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) application under Titles II and XVI of the Social Security Act. (D.I. 2; D.I. 15, at 5.) Salmons brought this civil action under 42 U.S.C. §405(g) as incorporated by 42 U.S.C. § 1383(c)(3). ( Id. )

Salmons initially applied for disability and disability insurance benefits on August 30, 2007. (D.I. 17 at 116-26.) Salmons' claims were denied initially and on reconsideration. Subsequently, claimant filed a request to have a hearing before an Administrative Law Judge ("ALJ"). (D.I. 17 at 6-7.) The claimant appeared and testified before the ALJ on May 7, 2009 before ALJ Melvin D. Benitz ("ALJ"). (D.I. 17 at 21-68.) On August 19, 2009, the ALJ issued an unfavorable decision against claimant. ( Id. at 8-20.) The Appeals Council denied review on August 4, 2010 and the ALJ's determination became final. 20 C.F.R. §§ 404.955, 404.981, 416.1455, 416.1481 (2012); Sims v. Apfel, 530 U.S. 103, 107 (2000); Matthews v. Apfel, 239 F.3d 589, 592 (3d Cir. 2001).

Before the court is Salmons' motion for summary judgment and defendant's cross-motion for summary judgment. (D.I. 15; D.I. 19.) For the reasons that follow, the court will deny Salmons' motion and grant defendant's cross-motion. The court will affirm the decisions of the Administrative Law Judge ("ALJ") and the Appeals Council. The court's reasoning follows.


A. Salmons' Medical Records

Salmons submitted medical records in support of his DIB and SSI applications. These medical records document several different medical issues including: cardiovascular issues, degenerative disc disease, depression, and numbness in his left hand.

1. Hand Injury and Raynaud's Phenomenon

Salmons suffered an injury to his left hand on December 3, 2003, as a result of an approximately 301b steering knuckle falling on him. (D.I. 17 at 232.) The external injuries were minor and characterized as a "mild contusion, " but, as a result, Salmons experienced cold intolerance and numbness in his index and long finger since the accident. ( Id. ) After visiting Dr. Nappi on December 16, 2003, Salmons was diagnosed with Raynaud's phenomenon. ( Id. ) He saw Dr. Nappi once per month and in June 2004, he was approved to return to work with no restrictions; however he continued to see Dr. Nappi every month. ( Id. at 226, 235.) He continued to experience the Raynaud's symptoms, especially when it was colder. ( Id. at 223-24.) In May 2005, Salmons was evaluated for workers' compensation and was continuing to experience pain, swelling, decreased motion, and discoloration of the fingers when the temperature fell below 70 degrees. ( Id. at 624.)

2. Cardiovascular Issues

On August 10, 2007, Salmons was hospitalized for a myocardial infarction and coronary artery disease. ( Id. at 243-46, 268-77.) He was treated and discharged from the hospital in stable condition. ( Id. at 276-77.) In November 2007, Salmons visited the hospital again for chest pain and also for numbness in his left arm and face. ( Id. at 311-15, 320-22, 465-67.) His EKG and other testing done revealed no new myocardial infarction, but an x-ray of his cervical spine showed degenerative disc disease at C6/C7 with posterior spurs. ( Id. at 466-67, 469.) Salmons again sought emergency room treatment for chest pain and numbness on his left side in February 2008. ( Id. at 379-80, 383-90, 440.) His pain was "completely resolved" with medication and all testing results came back normal. ( Id. at 383.)

Salmons also sought the care of Dr. Altajar from October 2007 until April 2008 for his occasional complaints of chest pain and numbness on the left side. ( Id. at 304-06, 328-30, 440-45, 497-99, 500-07.) The initial physical exam was generally normal, except that the left hand was cold. ( Id. at 305-06.) A further test on Salmons' heart rhythm showed no problems. ( Id. at 333.) During the rest of the examinations that Dr. Altajar conducted on Salmons from December through April there were normal physical findings including: cardiovascular, musculoskeletal, and neurological. ( See id. at 328-29, 441-45, 501-02, 504-05.) No other coldness or stiffness in the left hand were observed. ( Id. ) A second heart catheterization showed improvement and Salmons' medicine regimen was continued. ( Id. )

Salmons was also treated at the Community Care Family Clinic several times. ( Id. at 342-46, 427-28, 519-20.) This clinic diagnosed Salmons with neuropathy of his left upper extremity and a thyroid nodule. ( Id. at 427.) In May 2008, Salmons developed pain in his left arm after a golf outing and visited the Community Care Family Clinic. ( Id. at 519.)

In April 2008, Salmons' file was reviewed by State agency medical consultant Dr. Holifield who found that Salmons retained the physical capacity to perform full range of light work. ( Id. at 509-16.) In August 2008, he was examined by State agency medical consultant Dr. Ponterio who came to the same conclusion. ( Id. at 548-55.)

Dr. Adili-Khams treated plaintiff from August until October 2008 for several of his medical issues including; tobacco use, depression, hearing loss, back pain, left hand numbness, pain in the left arm, and hyperlipedmia. ( Id. at 586-87, 590-92.)

Dr. Oliveira, a cardiologist, saw Salmons between September 2008 and March 2009. ( Id. at 588-89, 593-96.) Dr. Oliveira determined through cardiac testing that Salmons' heart function.... had improved greatly since August 2007 and was in fact completely normal. ( Id. ) No more chest pain was reported and his coronary artery disease was reported as stable. ( Id. at 593.)

3. Degenerative Disc Disease and Back Pain

Dr. Thomas, a neurologist, saw Salmons between September 2008 and February 2009 for his left side numbness. ( Id. at 564-75.) Salmons' neurological examinations were found to be normal. ( Id. at 565-66, 568-69, 571-72, 575-76.) Dr. Thomas ordered an EMG of Salmons' left arm in October 2008 which showed mild chronic cervical polyradiculopathy. ( Id. at 576.) A MRI of Salmons' spine in September 2008 was positive for degenerative spondylosis at the C6/C7 level, with neural foraminal stenosis. ( Id. at 578.) In November 2008, an MRI of the lumbar spine showed degenerative disc disease with canal narrowing and evidence of herniation at the LS/SI level. ( Id. at 579-80.) Dr. Thomas diagnosed Salmons with lumbar disc disease, cervical and lumber radiculopathy, and other conditions relating to his prior cardiac problems. ( Id. at 569, 572, 575.)

Upon referral from Dr. Thomas, Dr. Sabbagh, an orthopedic surgeon, examined Salmons. ( Id. at 572, 610.) Dr. Sabbagh also diagnosed Salmons with degenerative disc disease at the L5-SI and L4-5 with herniation at L5-S1. ( Id. at 610.) He recommended pain management surgery for Salmons. ( Id. ) Salmons returned to Dr. Sabbagh in April 2009 and said that he wanted to have the surgery. ( Id. at 609.) In April 2009, Dr. Thomas supported Salmons' disability claim and indicated that he would be unable to work based on back issues, more specifically his lumber impairment. ( Id. at 613-18.)

B. Hearing Testimony

1. Salmons' ...

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