LAWRENCE E. KAHN, District Judge.
This case has proceeded in accordance with General Order 18, which sets forth the procedures to be followed in appealing a denial of Social Security benefits. Both parties have filed briefs. Dkt. Nos. 12 ("Plaintiff's Brief"); 13 ("Defendant's Brief"). For the following reasons, the judgment of the Social Security Administration ("SSA") is affirmed.
Plaintiff Jacqueline A. Strobino Travis ("Plaintiff") has a long history of health issues including multiple anxiety disorders, depression, drug and alcohol abuse, lumbar pain, left knee pain, and left ankle pain.
Plaintiff was first referred to Columbia County Mental Health ("CCMH") by her Probation Officer in February 1997, after she reported having "outbursts" and claimed to have been previously treated for bipolar disorder at Duchess County Mental Health. R. at 216. Plaintiff had a history of alcohol and heroin abuse at the time of her admission. R. at 217. She denied having any hallucinations or suicidal thoughts, and otherwise appeared well-oriented, but admitted to general anxiety and sleep disturbances such as going to bed at midnight and waking in the middle of the night, sometimes for several hours at a time. R. at 218. A psychiatric social worker at CCMH diagnosed Plaintiff with bipolar I disorder, cocaine dependence, alcohol abuse, and antisocial personality disorder. R. at 220. Plaintiff was then scheduled to begin treatment at Twin Co. Alcohol and Substance Abuse Services on March 10, 1997. R. at 219.
Plaintiff was admitted to CCMH a second time on October 16, 2000, and referred to a different recovery program — an alcohol and substance abuse rehabilitation program, McPike, followed by a halfway house, Perrin House. R. at 221. An assessment by psychologist J. C. O'Leary ("O'Leary") on November 19, 2000 found Plaintiff's polysubstance and alcohol dependence to be in early full remission, ruled out bipolar I disorder, and determined Plaintiff's primary diagnosis to be Borderline Personality Disorder. R. at 223-24. O'Leary noted that Plaintiff had a long history of dramatic mood changes, rash judgments, anti-social behaviors, and drug and alcohol abuse, and appeared anxious, distracted, and disheveled during her mental evaluation. R. at 226-28. Plaintiff was prescribed medication for symptoms of anxiety and depression. R. at 293. Plaintiff remained at McPike from December 5 until December 27, 2000, then moved to Perrin House, and finally returned to CCMH in April 2001 following completion of her treatment program. R. at 231. Plaintiff was prescribed a number of medications for anxiety and depression through March 2003 . R. at 292-93.
Plaintiff was later treated at Westchester Medical Center ("WMC") for second-degree burns and other injuries resulting from a house fire in April 2005. R. at 297. In this incident, Plaintiff's hair and arms caught on fire, and she burned her hands while attempting to put it out. R. at 301. She was able to escape the house after fifteen minutes by breaking out of a window, but sustained slight nasal burns and smoke inhalation before she escaped.
CCMH records from 2004 and 2005 reveal Plaintiff's continued history of alcohol and substance abuse and denial of a need for treatment, as well as an explosive temper, poor judgment, and poor impulse control. R. at 330-31. Dr. Carl Rinzler ("Dr. Rinzler") made an additional diagnosis of Dysthymic Disorder following Plaintiff's readmission to CCMH on December 21, 2004, after Plaintiff reported significant impairment in daily life functioning due to a chronically depressed mood over a two-year period, and issues with anger management.
Plaintiff visited the emergency room again on May 10, 2006, and complained of back pain. R. at 369. Physician's Assistant ("PA") Todd Santiago noted that the pain was severe and had begun the previous day following a fall, and that Plaintiff had no history of chronic pain or a degenerative spine.
Plaintiff returned to Columbia Memorial Hospital on three separate occasions in May 2011 for ankle pain. R. at 404, 409, 413. PA David Demboski ("Demboski") treated Plaintiff for left ankle pain after she fell down some stairs at home while taking out the garbage. R. at 404. Plaintiff had trouble bearing weight on the ankle and was diagnosed with swelling of lateral soft tissue but no fracture. R. at 406. Plaintiff was given medication during treatment and prescribed additional medication as needed for pain. R. at 405. She returned a few days later on May 22, 2011, complaining of continued ankle pain and stating that it was preventing her from sleeping at night. R. at 409. Demboski again prescribed Plaintiff medication for her ankle sprain. R. at 410. Plaintiff returned a third time on May 26 due to lack of improvement of the ankle, and she was prescribed pain medication. R. at 414. Her ankle remained tender and colored purple and brown due to bruising.
Plaintiff next saw Dr. Christopher Gorczynski ("Dr. Gorczynski") at Columbia Memorial Bone and Joint on June 6, 2011, regarding her ankle. R. at 425-26. Dr. Gorczynski noted pain in the entirety of Plaintiff's left ankle, which occasionally radiated up the entirety of her left leg, there was tingling in the bottom of her foot, and the pain was aggravated by weight bearing, walking, and any other movements. R. at 425. An x-ray revealed that the ankle had no fracture or deformity, but Plaintiff was prescribed pain medication, fitted with a walker boot, and given a home exercise program to help treat the pain. R. at 426. Plaintiff went to CMH Rehab Services for physical therapy treatment for the ankle on June 29, 2011. R. at 437.
A consultative orthopedic examination by Dr. Suraj Malhotra ("Dr. Malhotra") was conducted on June 13, 2011, after Plaintiff was referred to him by the Division of Disability Determination. R. at 427. Dr. Malhotra diagnosed Plaintiff with lumbosacral spine region pain and possible diskogenic disease, pain in the left knee with possible internal derangement, and a recently sprained left ankle. R. at 429. The examination determined that Plaintiff had a mild limitation in walking and moderate bending limitations in her left knee and ankle. R. at 430. A lumbosacral spine x-ray showed that there were no significant structural bony abnormalities, as the height of the vertebral bodies and intervertebral disc spaces were relatively well maintained. R. at 431.
A consultative psychiatric evaluation of Plaintiff by Dr. Seth Rigberg ("Dr. Rigberg") on June 28, 2011, determined that Plaintiff remained depressed and anxious but had seemingly remained sober from cocaine and alcohol for the previous five years.
State agency Single Decision Maker ("SDM") M. Mayer ("Mayer") made a physical residual functional capacity ("RFC") assessment of Plaintiff on August 3, 2011. R. at 71. Mayer found that Plaintiff could occasionally lift or carry twenty pounds, frequently lift or carry ten pounds, stand or walk for at least two hours in an eight hour workday, sit for a total of six hours in an eight hour workday, and push or pull without limitations in using her upper and lower extremities. R. at 67. Mayer also noted that Plaintiff had no manipulative, visual, communicative, or environmental limitations. R. at 68-69. However, he found that Plaintiff suffered from various occasional postural limitations involving climbing, balancing, and stooping. R. at 68.
State agency non-examining psychiatrist Dr. Dambrocia concluded on August 18, 2011, that Plaintiff still suffered from major depressive disorder, PTSD, generalized anxiety disorder, and panic disorder with agoraphobia. R. at 444, 446. With respect to Plaintiff's possible functional limitations, Dr. Dambrocia determined that Plaintiff's psychiatric issues would cause mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence, or pace. R. at 451. He also found that Plaintiff would be moderately limited in performing within a regular schedule, the ability to complete a normal workday and workweek without interruptions from psychological symptoms, the ability to interact appropriately with the general public, the ability to respond appropriately to changes in the work setting, and the ability to travel in unfamiliar places or use public transportation. R. at 455-56.
Hudson Medical Care office notes from the same day show that Plaintiff was evaluated by nurse practitioner Marilyn Miller ("Miller") after again complaining of having trouble sleeping, back pain, and left leg pain. R. at 467. Plaintiff underwent x-rays of her chest, abdomen, hip, lower back, and knee and was prescribed Clonidine tablets and Prilosec delayed release capsules to combat her insomnia. R. at 468.
Plaintiff visited the Columbia Memorial Hospital emergency room four more times between July 2011 and April 2012. R. at 469, 496, 502, 517. PA Cassandra Sobkiw-Kurtz ("Sobkiw-Kurtz") treated Plaintiff on July 30, 2011, primarily for her back pain, treating her with Morphine and Zofran and prescribing Flexeril and Prednisone to help decrease inflammation. R. at 522. Plaintiff claimed to be off of drugs and alcohol, but the medical report noted that her urine sample was suspicious since the results were negative for drugs, even though she had taken Percocet that morning. R. at 527. Plaintiff returned to the emergency room on August 28, 2011, after experiencing abdominal pain, and was treated by Dr. John Keene ("Dr. Keene"). R. at 503. Dr. Keene prescribed Doxycycline, Flagyl, and Lortab, and testing determined that everything appeared normal in Plaintiff's abdominal region. R. at 511-12. Plaintiff returned a third time on March 26, 2012, complaining of a painful lump under her arm and chest pain. R. at 497. Sobkiw-Kurtz prescribed medication for the pain and performed a chest x-ray before diagnosing Plaintiff with a chest wall strain. R. at 499. Plaintiff was discharged the same day after she claimed to feel much better. R. at 500. Plaintiff visited the emergency room a final time on April 17, 2012, again complaining of chest pain to Dr. Michael Weisberg ("Dr. Weisberg"). R. at 530. Dr. Weisberg prescribed Zithromax, Zantac, and Prednisone and found that, while there was mild elevation of the left hemidiaphragm and possible atelectasis, the tests on Plaintiff's chest were otherwise unremarkable. R. at 541.
Hudson Medical Care office notes from August 30, 2012, show that Plaintiff was again evaluated by Miller after she claimed her medications were not working, and requested a prescription for Prilosec because of her constant physical pain. R. at 546. Plaintiff was found to still have lumbago, acute knee pain, and hip pain, was prescribed Prilosec for the lumbago, and was referred to an orthopedist for back, knee, ankle, and hip pain. R. at 546-47.
Plaintiff returned to the Bone and Joint Center a month later in September 2012 after reinjuring her left knee and ankle when her leg gave out and she fell on top of the ankle. R. at 548. Plaintiff claimed her knee had been bothering her since she was fifteen years old following a horseback riding accident, causing it to become chronically painful and unstable.
Plaintiff was also diagnosed at the Spine Institute with spondylolisthesis by Dr. Ersno Eromo following complaints of continued back pain and a spinal x-ray on September 17, 2012. R. at 552. After Plaintiff was also found to have degenerative disc disease the following month, Dr. Tomasz Andrejuk ("Dr. Andrejuk") of Columbia Memorial Pain Management performed a procedure on Plaintiff's back to alleviate discomfort on October 24, 2012. R. at 556. Plaintiff tolerated the procedure well and claimed it reduced her discomfort.
On April 20, 2011, Plaintiff filed an application for supplementary security income, alleging disability beginning November 1, 2006, due to pain and discomfort from anxiety, depression, and physical impairments including lumbar, left knee, and left ankle pain. R. at 16, 208. The SSA denied the application on August 8, 2011, and Plaintiff subsequently filed a written request for a hearing before an Administrative Law Judge ("ALJ") on October 18, 2011. R. at 16. On September 13, 2012, ALJ Robert Wright conducted a hearing regarding Plaintiff's claim with her counsel and impartial vocational expert ("VE") Peter A. Manzi ("Manzi") present.
ALJ Wright asked Plaintiff questions pertaining to her work capabilities, current medical state, and daily life activities. R. at 42-51. Plaintiff claimed that though she could not recall definitively at which point she last worked, her previous employment position as a housekeeper ended sometime between 1999 and 2002. R. at 39-40. Plaintiff testified that she had stopped working due to panic attacks and incarceration. R. at 41. When asked why she felt she was unable to work, Plaintiff testified that her panic attacks keep her from getting a job and that she is unable to stand for more than one hour due to physical pain in her back and right leg from degenerative arthritis and general instability of her left knee. R. at 50-51. Plaintiff testified that on a typical day she mostly stays inside her apartment to watch TV, but performs household chores like cooking and light cleaning. R. at 45. While grocery shopping and laundry are too difficult for Plaintiff to do alone due to her panic attacks and physical pains, Plaintiff is able to walk up the street and back to pick up her mail, as well as take trips to visit her aunt in Hudson, New York. R. at 45-46, 48-49.
After the ALJ's questioning, Plaintiff's counsel further inquired into Plaintiff's medical status and functional capacity. R. at 52-57. Counsel asked about Plaintiff's ability to sit, walk, and lift. R. at 51-53. Plaintiff claimed she could only sit for around forty minutes, lift a bit more than the weight of a gallon of milk, and walk about a half a block before experiencing back pain.
VE Manzi then testified regarding Plaintiff's prior work experience. R. at 61. Plaintiff had done light and unskilled work as a housekeeper, and medium and semi-skilled work as a presser.
ALJ Robert Wright issued a decision denying Plaintiff's application for disability and supplemental security income ("SSI"). R. at 16. The ALJ found that Plaintiff had not engaged in any substantial gainful activity since April 20, 2011. R. at 18. The ALJ then found that Plaintiff did suffer from severe impediments, including lumbar spondylosis, affective disorders, and anxiety.
Plaintiff filed a review request on November 1, 2012. R. at 1. On February 12, 2014, the ALJ decision became the final decision of the Commissioner when the Appeals Council denied the request for review. R. at 1-3. Plaintiff filed a timely appeal on April 11, 2014. Dkt. No. 1 ("Complaint").
When a court reviews the SSA's final decision, it determines whether the ALJ applied the correct legal standards and if the ALJ's decision is supported by substantial evidence in the record. 42 U.S.C. § 405(g);
According to SSA regulations, disability is "the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 20 C.F.R. § 404.1505(a). An individual seeking disability benefits "need not be completely helpless or unable to function."
At step one, the SSA considers claimant's current work activity to see if it amounts to "substantial gainful activity." 20 C.F.R. § 404.1520(a)(4)(I). If it does, claimant is not disabled under SSA standards.
Plaintiff argues that: (1) the ALJ failed to adhere to Social Security Ruling 96-6p by ignoring the opinion of state agency SDM Mayer, which suggested Plaintiff was limited to sedentary work; and (2) the ALJ's determination of Plaintiff's RFC is not supported by substantial evidence in the record based on the opinions and conclusions of Dr. Dambrocia and Dr. Rinsberg. Pl.'s Br. at 3-5.
When considering a claim for SSI due to disability, the ALJ must comply with SSR 96-6p by considering and explaining the weight given to the opinions of "[s]tate agency medical and psychological consultants and other program physicians and psychologists regarding the nature and severity of an individual's impairment(s)."
There is no evidence that Mayer is either a trained physician or psychologist, or that he personally examined Plaintiff when recording his RFC evaluation. R. at 66-72. Indeed, the record clearly shows that Mayer is not a physician and did not personally examine Plaintiff.
Despite this, Plaintiff claims that the ALJ still should have accounted for the determination of the SDM and provided a justification for why the SDM's determination was rejected.
The ALJ thus acted appropriately in not considering the RFC determination made by the SDM in the instant case. R. at 24-27. The ALJ correctly incorporated the medical evidence and other evidence in the record, including the opinion of consultative examiner Dr. Suraj Malhotra and the examination by Dr. Scott Pregont, which support his conclusion that Plaintiff possesses a physical RFC for light work. R. at 24-27, 427-31, 548-50.
Plaintiff next argues that the ALJ's RFC determination is not supported by substantial evidence due to the ALJ's: (1) failure to give any weight to Mayer's opinion; (2) giving significant weight to the opinion of consultative psychological examiner Dr. Rigberg; and (3) giving greatest weight to the opinion of state agency psychological consultant Dr. Dambrocia while failing to account for Dr. Dambrocia's determination that Plaintiff was "moderately limited" in several aspects.
As part of the evaluation process, a claimant's RFC must be determined before applying step four of the disability benefits test.
The ALJ properly considered the opinion of consultative examiner Dr. Rigberg by giving it significant weight, but declining to incorporate it in its entirety. R. at 26. He instead determined that Dr. Dambrocia's opinion was of greater probative value and more consistent overall with the evidence in the record.
The ALJ also properly considered that the examination performed by Dr. Rigberg did not uncover determinations that would establish Plaintiff's asserted limitations.
The ALJ also correctly adopted the evaluation of state agency medical consultant Dr. Dambrocia, who reviewed Dr. Rigberg's report and the rest of the evidence in the Record.
In the instant case, Dr. Dambrocia recorded in Section III that Plaintiff was able to comprehend instruction and sustain concentration for tasks, but also may have difficulty relating to others or adapting to changing circumstances, and would benefit from a low-contact atmosphere. R. at 26, 457. The ALJ properly accorded Dr. Dambrocia's assessment significant weight since his opinion supports the ALJ's mental RFC determination for unskilled work in a low-stress occupation. R. at 23-27. According significant weight to the opinion is further supported by the fact that Plaintiff was found to possess adequate social skills, good eye contact and motor skills, minor issues with attention and concentration abilities, and the ability to perform numerous activities, which all support Dr. Dambrocia's opinion.
In conclusion, the ALJ was correct in his determination of Plaintiff's RFC because he properly evaluated all of the relevant evidence, and his RFC determination is supported by substantial evidence in the Record.
Accordingly, it is hereby: