United States District Court, D. Delaware
Jo Ann Matthias, Georgetown, Delaware, Pro Se Plaintiff.
Charles M. Oberly, III, Esquire, United States Attorney and Heather Benderson, Esquire, Special Assistant United States Attorney, of the Office of the United States Attorney, Wilmington, Delaware. Of Counsel: Nora Koch, Esquire, Acting Regional Chief Counsel, Region III and Evelyn Rose Marie Protano, Esquire, Assistant Regional Counsel, of the Social Security Administration, Philadelphia, Pennsylvania.
LEONARD P. STARK, District Judge.
Plaintiff Jo Ann Matthias ("Matthias" or "Plaintiff') appeals from the decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security ("Commissioner" or "Defendant"), denying her application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The Court has jurisdiction pursuant to 42 U.S.C. § 405(g). Presently pending before the Court are cross-motions for summary judgment filed by Matthias and the Commissioner. (D.I. 26, 27) For the reasons set forth below, the Court will deny Plaintiff's motion and will grant Defendant's motion.
A. Procedural History
Matthias filed her application for DIB on July 7, 2010, alleging disability beginning November 6, 2008. The application was denied in October 2010, and upon reconsideration on March 14, 2011. Matthias filed a request for hearing on March 22, 2011. On July 11, 2011, a hearing was held before an Administrative Law Judge ("ALJ") who issued a decision finding that Matthias was not disabled under the Act. Matthias filed a request for review by the Appeals Council, which was denied on August 15, 2012 and the ALJ's decision became the final decision of the Commissioner. (D.I. 21 ("Tr.") at 1-5)
On September 25, 2012, Matthias filed a Complaint seeking judicial review of the ALJ's July 21, 2011 decision. (D.I. 2) Matthias moved for summary judgment on October 1, 2014 (D.I. 26), and the Commissioner filed a cross-motion for summary judgment on October 30, 2014 (D.I. 27).
B. Medical and Mental Health Evidence
Plaintiff was admitted to Atlantic General Hospital in Berlin, Maryland, on September 15, 2008 with bilateral leg weakness and complaints that she could not walk. (Tr. at 202) She was hospitalized for four days. Upon admission, Plaintiff could not lift her legs off the examination table, and she was unable to ambulate or sustain her weight. ( Id. ) Plaintiff had pain with movement, and stated that the pain was almost non-existent at rest. ( Id. ) As of September 19, 2008, Plaintiff complained of significant leg weakness as well as pain and weakness in her arms which seemed to gradually progress and then suddenly worsen. ( Id. at 198) Impression was a "suspicion of Guillain-Barre or other muscular motor neuron problems." ( Id. at 205)
While hospitalized, Plaintiff underwent a number of studies, including a CT scan, MRIs, and an MRA. ( Id. at 198, 208-10, 211, 212, 214, 220) The brain CT scan and the MRI and MRA of the brain were normal. ( Id. at 198, 211, 214-15, 220) The MRI of the thoracic revealed no thoracic disc herniation or significant central canal or foraminal narrowing; the MRI of the lumbar spine revealed a mild central canal narrowing at the L4-L5 level caused by diffuse disc bulge and facet joint hypertropic change, with mild disc bulges seen elsewhere; and the MRI of the cervical spine revealed a disc bulge at the C5-C6 level. ( Id. at 208-10, 212, 220) Other tests were ordered, but at discharge the results were pending. ( Id. at 198-99)
While hospitalized, Plaintiff improved significantly. Her leg pain resolved and leg weakness significantly improved. ( Id. at 199) Upon discharge, she could ambulate on her own and was steady. ( Id. ) Plaintiffs discharge diagnoses included acute peripheral neuropathy which improved, and "possibly Guillain-Barre but other workup still pending, " vitamin B12 deficiency, lumbar disc bulges and a cervical disc bulge, history of idiopathic thrombocytopenic purpura,  hypomagnesemia, history of anemia but now stable CBC, and history of gastric by-pass. ( Id. at 200).
Joseph Karnish, D.O. ("Dr. Karnish") has been Plaintiffs primary care physician for more than 15 years. ( Id. at 303) Plaintiff saw Dr. Karnish on September 29, 2008 for "ascending paralysis, possibly Gilillain-Barre syndrome." ( Id. at 245) He noted the extensive hospital work-up, and that Plaintiff indicated she continued to note diffuse weakness. ( Id. at 256) Plaintiffs strength was 4/5, and she was able to arise independently from the exam room chair. ( Id. ) The etiology for her myalgia and weakness was unclear. ( Id. )
Plaintiff was seen by neurologist Dr. Gordana Peric-Stepcic ("Dr. Peric-Stepcic") on two separate occasions, September 30, 2008 and October 14, 2008. On September 30, 2008, Dr. Peric-Stepcic noted that Plaintiff continued to have numbness in both feet with leg weakness. ( Id. at 236) She walked slowly without support on broader base and was unable to tolerate prolonged standing or walking. ( Id. at 236, 238) Dr. Peric-Stepcic noted 4/5 proximal leg muscle strength decreased toe movements, and 4 feet dorsiflexion. ( Id. at 238) Dr. Peric-Stepcic noted that Plaintiff's systems were improving, and that they "could be due to Guillain-Barre syndrome which improved spontaneously, " although other neuropathies were possible. ( Id. at 239) Dr. Peric-Stepcic found that Plaintiffs muscle strength and hypoesthesia improved on a daily basis during her hospital stay. ( Id. ) Plaintiff was to continue doing home exercises and to begin physical therapy if she did not improve. ( Id. ) Dr. Peric-Stepcic noted that Plaintiff was unable to work due to her symptoms. ( Id. )
Dr. Peric-Stepcic reported on October 7, 2008 that that the etiology of Plaintiffs peripheral neuropathy was unclear, but that she had been "improving a lot" since her initial presentation at the hospital. ( Id. at 243) Plaintiff had started physical therapy the prior week. (Id.) Dr. Peric-Stepcic noted that Plaintiff regained all of her reflexes except at the ankle regions and that she was stronger with an improved sensory examination. ( Id. )
In an October 14, 2008 letter, Dr. Karnish stated that he "evaluated Jo Ann yesterday for her work capacity based upon her recent diagnosis of Guillain-Barre syndrome. She appears to be recovering adequately at this time." ( Id. at 231) Dr. Karnish noted that Plaintiff could begin parttime work (a maximum of 8 hour shifts with a maximum of thirty-six hours per week) effective October 17, 2008. ( Id. ) On October 16, 2008, Dr. Karnish noted that Plaintiff had "acute peripherally neuropathy.... possibly Guillain-Barre syndrome." ( Id. at 230) Dr. Karnish expected Plaintiff to return to unrestricted work on November 3, 2008 if all went well. ( Id. at 231) On October 21, 2008, Dr. Karnish noted that Plaintiff continued to have difficulty with rote memorization. ( Id. at 229)
Plaintiff presented to Dr. Karnish on November 5, 2008 to discuss her fear of recurrent descending paralysis symptoms. ( Id. at 255) She described recurrent pain and numbness in her feet having occurred on November 2, with eventual weakness and numbness of her thighs, and a stumbling gait. ( Id. ) Plaintiff reported that, since November 2, there had been no further progression of her symptoms. ( Id. ) Upon examination, Dr. Karnish found that Plaintiff's knee and hip flexors were 4 to 4 /5 upon strength testing. ( Id. ) He prescribed Lexapro for depression/ anxiety. ( Id .) Plaintiff saw Dr. Karnish on January 15, 2009 to address right hip pain. ( Id. at 254) The pain was treated with oxycodone. ( Id. at 254, 255)
Plaintiff presented to Dr. Karnish on April 9, 2009 with severe leg pain, which Dr. Karnish stated could be a residual effect of Guillain-Barre syndrome. ( Id. at 251) He "[a]dvised [patient] today I have limited experience w/Guillain-Barre syndrome and cannot specifically state which [symptoms] are related to this disease process." ( Id. ) Dr. Karnish noted Plaintiff's chronic back and leg pain were interfering with her qualify of life and that the pain was uncontrolled by MSIR (i.e., morphine). ( Id. ) Dr. Karnish discussed various types of medication therapy. He suspected "depression may also be in play." ( Id. )
When Plaintiff saw Dr. Karnish on May 12, 2009, she reported that her knees gave out and that she had fallen for a fourth time. ( Id. at 252) That morning, her son had to drag her to their vehicle but, by the time of her office visit, Plaintiff was able to ambulate with more independence. ( Id. ) As her paresthesia began to recede, Plaintiff noted improving strength, but she did not return to baseline. ( Id. ) Dr. Karnish noted, "there appears to be some type of neurologic process but I am not able to define it." ( Id. ) On May 18, 2009, Plaintiff complained to Dr. Karnish of worsening pains in her knees and more stiffness. ( Id. at 250) Plaintiff advised Dr. Karnish that she had helped her son move during the past weekend and this required carrying heavy objects and increased ambulatory time. ( Id. ) During a July 31, 2009 appointment with Dr. Karnish, Plaintiff complained of worsening restless legs and an inability to afford her medication. ( Id. at 249) She complained of chronic persistent pain, and Dr. Karnish renewed a prescription for morphine. ( Id. )
On August 25, 2009, Plaintiff advised Dr. Karnish of a recent argument with her daughter that resulted in an exchange of blows. ( Id. at 248) She denied worsened paresthesia and weakness of her legs following a blow to her head. ( Id. ) Plaintiff relayed that the altercation aggravated her depression and, as a result, Dr. Karnish increased her dose of Lexapro. ( Id. ) When Plaintiff was seen on October 13, 2009 for pain management, she complained that the pain seemed to emanate from her hip, although she also had diffuse myalgia. ( Id. at 247)
On September 7, 2010, Plaintiff saw Dr. Karnish for a new type of lower back and left leg radicular pain. ( Id. at 308) Plaintiff had difficulty bearing weight on her leg, and "has been using a borrowed quad cane for assistance w/ambulation." ( Id. ) Plaintiff denied an increase in paresthesia from the baseline. ( Id. ) Her strength was limited by pain, but was 4/5 in the ankle plantar flexors, knee extensors, and hip extensors. ( Id. ) Dr. Karnish increased the prescribed morphine and Lyrica prescription with a plan to taper the medication after the pain was controlled. ( Id. )
Plaintiff was examined by State agency consultant Dr. Balepur Venkataramana ("Dr. Venkataramana") on September 24, 2010. ( Id. at 278) Plaintiff provided a history of weakness in both legs and difficulty walking, severe foot pain, without support she tends to fall, changed dexterity in her fingers, and an inability to complete household chores. ( Id. ) Plaintiff was unsteady and used a quad cane. ( Id. at 279) Because she was unable to get on the examination table, she was examined while sitting in a chair, ( Id. at 280) Upon examination, Dr. Venkataramana noted no muscle atrophy or muscle spasm, but that Plaintiff had limited neck and hip movement mainly due to weakness. ( Id. )
Medical consultant Anne Aldridge ("Aldridge") completed a physical residual functional capacity assessment of Plaintiff on October 4, 2010. ( Id. at 285) Aldridge determined that Plaintiff could: occasionally lift or carry twenty pounds; frequently lift or carry ten pounds; stand or walk about two hours in an eight hour day; and sit for six hours in an eight hour day. ( Id. at 286) The assessment noted that the magnitude of Plaintiffs alleged symptoms were disproportionate to the objective evidence, citing the following examples: (1) Plaintiffs quad strength was decreased only to 4/5 and her other muscle groups were 5/5 without evidence of atrophy; and (2) the suspicion of "Lou Gehrig's disease" was inconsistent with the medical records which did not include such a diagnosis. ( Id. at 289) Aldridge concluded that, because Plaintiff was a career nurse and would know the difference between the conditions, she was intentionally misrepresenting her diagnosis. ( Id. )
On October 5, 2010, Pedro Ferreira, Ph.D. ("Dr. Ferreira") completed a psychiatric review of Plaintiff. ( Id. at 291) Dr. Ferreira noted that Plaintiff had a prescription for Lexapro and Klonopin from her primary care physician to manage depression and help with anxiety and that she reported responding favorably to these medications. ( Id. at 301) Dr. Ferreira found that Plaintiff had mild restrictions of daily living, maintaining social functioning, and maintaining concentration, persistence, or pace, with no episodes of decompensation. ( Id. at 299) He concluded that Plaintiff's mental health condition was non-severe. ( Id. at 301) On March 14, 2011, Carlene Tucker-Okine, Ph.D. ("Dr. Tucker-Okine") affirmed Dr. Ferreira's October 5, 2010 psychiatric review. ( Id. at 320)
When Plaintiff presented to Dr. Karnish on October 7, 2010, she stated that, due to pain, it sometimes takes her three hours to get out of bed and dressed. ( Id. at 307) Upon examination, Dr. Karnish noted that Plaintiff's strength was limited secondary to pain, with 4/5 strength in the ankle plantar flexors, knee extensors, and hip extensors. ( Id. ) Plaintiff relayed that, due to pain in her neck, she felt she had to be "extra vigilant while driving." ( Id. ) Pain management included taking three to four 30 mg. morphine tablets ...