United States District Court, E.D. Virginia, Richmond Division
REPORT AND RECOMMENDATION
DAVID J. NOVAK, Magistrate Judge.
Florence Michelle Hawkins ("Plaintiff") is forty-eight years old and previously worked as a medical assistant. On December, 15, 2011, Plaintiff applied for Social Security Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under the Social Security Act ("Act"). Both claims stemmed from degenerative disc disease, obstructive sleep apnea, anxiety disorder, affective disorder and obesity, with an alleged onset date of September 23, 2011. Plaintiff's application was denied both initially and upon reconsideration. On September 10, 2013, Plaintiff testified before an Administrative Law Judge ("ALJ"). On October 2, 2013, the ALJ issued a written decision denying Plaintiff's claims for DIB and SSI. On December 4, 2013, the Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner of Social Security.
Plaintiff now appeals the ALJ's decision in this Court pursuant to 42 U.S.C. § 405(g), arguing that the All erred by affording very limited weight to the opinion of Plaintiff's treating physician. Defendant responds that the ALJ did not err and that substantial evidence supports the ALJ's decision. The parties have submitted cross-motions for summary judgment that are now ripe for review.
Having reviewed the parties' submissions for summary judgment and the entire record in this case, the Court is now prepared to issue a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons that follow, the Court recommends that Plaintiff's Motion for Summary Judgment (ECF No. 12) and Plaintiff's Motion to Remand (ECF No. 13) be DENIED, that Defendant's Motion for Summary Judgment (ECF No. 17) be GRANTED and that the final decision of the Commissioner be AFFIRMED.
Because Plaintiff challenges whether the ALJ erred in affording very limited weight to Plaintiff's treating physician's opinion regarding her physical impairments, Plaintiff's education and work history, pertinent medical history, function report, Plaintiff's hearing testimony and vocational expert ("VE") testimony are summarized below.
A. Education and Work History
Plaintiff was forty-six years old when she applied for DIB and SSI. (R. at 26.) Plaintiff did not graduate from high school, but earned a GED and an associate's degree. (R. at 41, 259.) Plaintiff previously worked as a medical assistant, home health aide and security guard. (R. at 259.)
B. Medical Records
1. Bon Secours
On March 30, 2011, Plaintiff saw Sharon E. Joseph, M.D. at Bon Secours Powhatan Medical Group. (R. at 539-40.) Dr. Joseph noted that Plaintiff was a new patient at this office, but that she had seen Plaintiff previously at Dr. Joseph's former office. (R. at 540.) Plaintiff had no major medical concerns, and the primary purpose for her visit was to establish care and make sure that she was healthy before she lost her insurance coverage. (R. at 540.) A physical examination revealed trace edema in Plaintiff's legs, but yielded otherwise normal results. (R. at 540.) Dr. Joseph diagnosed Plaintiff with edema in both legs, vitamin D deficiency and acanthosis nigricans (a skin condition). (R. at 540.) She prescribed a refill of Plaintiff's Lasix prescription that she took for her edema. (R. at 540.)
On June 20, 2011, Plaintiff saw Naim S. Bashir, M.D. at the Bon Secours Sleep Disorders Center for a sleep medicine consultation. (R. at 339-40.) Plaintiff informed Dr. Bashir that she had been diagnosed with obstructive sleep apnea four years earlier and had been treated with continuous positive airway pressure ("CPAP") therapy. (R. at 339.) Approximately one year before this appointment, she began bilateral positive airway pressure therapy. (R. at 339.) Plaintiff told Dr. Bashir that she was unable to sleep comfortably while on her positive airway pressure therapy and that her sleep quality remained poor, despite her experimentation with different types of masks. (R. at 339.)
Dr. Bashir conducted a physical examination of Plaintiff and opined that she appeared well-developed, obese and well-groomed. (R. at 339.) Plaintiff's neck, chest, heart and abdomen appeared normal. (R. at 340.) Dr. Bashir observed no digital clubbing, cyanosis or edema in Plaintiff's extremities. (R. at 340.) Plaintiff appeared awake, alert, ambulating and oriented, and Dr. Bashir opined that she was "[a] pleasant individual with good mood and affect." (R. at 340.) Dr. Bashir assessed Plaintiff as having obstructive sleep apnea and difficulties with positive airway pressure therapy. (R. at 340.) He reviewed the fit of Plaintiff's CPAP mask and provided her a different kind of mask to try. (R. at 340.) Dr. Bashir adjusted the bilateral pressures of Plaintiff's CPAP mask and instructed her to follow up in two weeks. (R. at 340.)
On July 12, 2011, an overnight polysomnography showed that Plaintiff had normal electroencephanlography ("EEG") data, normal sleep latency (including normal light sleep and deep sleep), an increased percentage of rapid eye movement ("REM") sleep with decreased REM latency, two apneas and no significant oxygen desaturations at final pressure. (R. at 355, 358.) A multiple sleep latency test performed the following day showed no evidence of significant hypersomnia. (R. at 354.) During a follow-up appointment on July 25, 2011, Dr. Bashir described Plaintiff's sleep quality from the overnight polysomnography as excellent. (R. at 347.) He adjusted the pressure on Plaintiff's CPAP device and instructed her to use it nightly, referred her to a cardiologist for evaluation of her leg pain, noting that it was possibly due to peripheral vascular disease, and recommended that Plaintiff schedule follow-up appointments at the CPAP clinic and with him in thirty days and six months, respectively. (R. at 348.) On February 3, 2012, a repeat polysomnography indicated "no evidence of significant obstructive sleep apnea." (R. at 573-74.)
On July 30, 2011, Plaintiff saw Hedley Mendez, M.D., complaining of back pain stemming from a treadmill heart test two days earlier. (R. at 373.) Dr. Mendez noted that Plaintiff was married and sexually active, and that her risk factors included obesity and lack of exercise. (R. at 373-74.) On examination, Dr. Mendez observed that Plaintiff exhibited normal range of motion with right lumbar tenderness. (R. at 375.) Dr. Mendez diagnosed Plaintiff with sciatica. (R. at 373.) Dr. Mendez prescribed Valium, Percocet and Prednisone, and instructed Plaintiff to continue taking vitamin D3 and Lasix. (R. at 377.)
On August 3, 2011, Plaintiff returned to the emergency department at Bon Secours, complaining of right leg pain. (R. at 379.) X-rays revealed a normal right hip with no signs of abnormalities, normal lumbar spine alignment and well-preserved vertebral body heights. (R. at 380-81.) The imaging report noted mild spondylitic changes at L2-3 and L3-4 with no fracture, subluxation or other abnormality. (R. at 381.)
On September 4, 2011, Plaintiff again sought treatment at Bon Secours, complaining of chronic lower back pain on her right side. (R. at 384.) Plaintiff stated that she had been experiencing moderate intensity "shooting" pain for more than a week. (R. at 384.) Plaintiff indicated that her pain was associated with lifting and twisting, and that bending, twisting and certain positions aggravated her symptoms. (R. at 384.) Plaintiff reported paresthesias and tingling, but no chest pain, fever, numbness, abdominal pain or swelling, bowel or bladder incontinence, perianal numbness, paresis or weakness. (R. at 384.) She stated that Prednisone helped. (R. at 384.) Umaran H. Choudry, M.D. conducted an examination that revealed, in pertinent part, tenderness, normal range of motion and no signs of edema. (R. at 386.) Dr. Choudry increased Plaintiff's dose of Prednisone, prescribed Vicodin and Motrin, and continued her other medications. (R. at 389.)
On September 19, 2011, Plaintiff followed-up with Dr. Joseph regarding her emergency room visit. (R. at 526.) Plaintiff complained of worsening lower back pain that extended down her right leg. (R. at 526.) Upon examination, Plaintiff exhibited decreased range of motion in her lower back and numbness and pain extending down her right leg. (R. at 526.) She was alert and oriented to person, place and time, but displayed abnormal reflexes in both knees. (R. at 526-27.) Dr. Joseph recommended that Plaintiff undergo an MRI of her lumbar spine, because her recent x-rays revealed only spondylitic changes and her pain was worsening. (R. at 526-27.) Dr. Joseph refilled Plaintiff's prescription for Ultram and started her on Neurontin, and instructed her to return if her symptoms worsened or failed to improve. (R. at 527.) Subsequent MRI imaging of Plaintiff's lumbar spine revealed normal alignment, mild degenerative changes at L3-4 and L4-5, and a possible small synovial cyst abutting the slightly thickened left S1 nerve root. (R. at 403-04.)
On October 4, 2011, Plaintiff saw Brian J. Foster, M.D. for an initial visit regarding her back pain. (R. at 495.) Plaintiff informed Dr. Foster that she had visited the emergency room twice over the past summer for her back pain, and that her pain improved with steroid tapers and pain medication, including Neurontin and Tramadol. (R. at 495.) Plaintiff described her pain as radiating down her legs, with the right leg being more painful than the left leg. (R. at 495.) Plaintiff stated that lying down, leaning forward and taking a hot bath helped her pain, but sitting or standing too long worsened it. (R. at 495.) Dr. Foster performed a physical examination of Plaintiff that yielded normal results, including normal range of motion and a muscle strength rating of 5/5 in all muscle groups. (R. at 495.) fle assessed Plaintiff as having sciatica, chronic lower back pain and vitamin D deficiency, and referred her for physical medicine rehabilitation and evaluation by an orthopedic surgeon. (R. at 495.) Dr. Foster instructed Plaintiff to return in one month for a follow-up appointment for her back pain. (R. at 495.)
On November 1, 2011, Plaintiff saw Dr. Foster for a follow-up appointment regarding her back pain. (R. at 493.) The results of Dr. Foster's physical examination remained essentially unchanged from Plaintiff's appointment on October 4, 2011. (R. at 493.) Dr. Foster noted that Plaintiff's sciatica continued to bother her and that she was waiting on an orthopedic appointment at VCU Health System. (R. at 493.) Plaintiff had not followed through on Dr. Foster's physical medicine and rehabilitation referral due to her insurance, but Dr. Foster asked her to inquire about a payment plan. (R. at 493.) Dr. Foster instructed Plaintiff to take a vitamin D supplement and ordered lab work to recheck her hyperlipidemia. (R. at 493.) He diagnosed Plaintiff with anxiety and prescribed Citalopram. (R. at 493.)
On November 26, 2011, Plaintiff saw Alexis A. Dimaio, M.D., complaining of right back pain that shot down her buttock and right leg. (R. at 407.) Dr. Dimaio performed a physical examination that revealed a normal musculoskeletal range of motion with no edema and no tenderness. (R. at 409.) Plaintiff's straight leg raising test was negative bilaterally. (R. at 409.) Plaintiff was alert and oriented with normal mood and affect. (R. at 409.) Dr. Dimaio diagnosed Plaintiff with a urinary tract infection and sciatica. (R. at 407, 410.) Dr. Dimaio prescribed an antibiotic and recommended pain medications and follow-up with physical therapy. (R. at 410.)
2. Sheltering Arms Rehabilitation Center
Dr. Foster referred Plaintiff to the spine center at Sheltering Arms Rehabilitation Center, where Scott N. Schimpff, M.D. evaluated Plaintiff for complaints of pain in her lower back and both legs on December 12, 2011. (R. at 471.) Dr. Schimpff noted that Plaintiff's MRI showed multi-level degenerative disc and facet disease. (R. at 471-72.) He performed a physical examination of Plaintiff and reported 1 pitting edema in both legs and swelling on palpation, bilateral patellar deep tendon reflexes of 1, normal sensation to light touch, tenderness on palpation in Plaintiff's lower back, muscle strength of 5/5 in all major muscle groups, positive bilateral straight leg raise and an increase in lower back pain with forward flexion. (R. at 472.) Dr. Schimpff assessed Plaintiff as having lumbar radiculopathy, lumbar degenerative disc disease, lumbar spondylosis, obesity and a sleep disorder. (R. at 472.) He ordered physical therapy and prescribed a transcutaneous electrical nerve stimulation (-TENS-) unit for home use, as well as Amitriptyline. (R. at 472.) In addition, Dr. Schimpff recommended an epidural steroid injection in her back, which Plaintiff declined. (R. at 472.)
On February 13, 2012, Plaintiff returned to Dr. Schimpff, complaining of pain in her lower back, both legs and both arms. (R. at 464.) She stated that the TENS unit was very effective, the Amitriptyline prescription was effective and that she had made some progress with physical therapy and a home exercise program. (R. at 464.) Plaintiff reported that her symptoms had improved approximately fifteen percent since her last office visit. (R. at 464.) On examination, Dr. Schimpff observed paraspinal tenderness to palpation over the spinous processes between Plaintiff's L4 and S1 vertebra. (R. at 465.) Plaintiff requested that Dr. Schimpff complete disability paperwork for her at her appointment. (R. at 464-65.) He informed Plaintiff that he could not fill out the forms until she completed a physical performance evaluation. (R. at 465.)
On April 25, 2012, Plaintiff visited Deborah Hill-Barlow, Ph.D., a clinical psychologist, for a psychological evaluation and to obtain treatment recommendations for her chronic painrelated depression and anxiety. (R. at 661.) In her evaluation, Dr. Hill-Barlow reported that Plaintiff favored her right side as she sat, had goal-directed thoughts and exhibited no signs of a formal thought disorder or psychosis. (R. at 663.) Dr. Hill-Barlow recommended therapy sessions to help with Plaintiff's depression and anxiety. (R. at 663.) Plaintiff attended her first counseling session the following week on May 2, 2012. (R. at 660.)
After a six-month gap, Plaintiff returned to counseling on November 15, 2012. (R. at 658.) At each of her three counseling appointments with Dr. Hill-Barlow in November and December 2012, Plaintiff complained of depression. (R. at 656-58.) On May 7, 2013, Plaintiff reported to Dr. Hill-Barlow that she had been attempting to move more and walk in the mall. (R. at 655.) Plaintiff expressed frustration that she could not think of a job that she could physically perform in light of her inability to remain in one position for more than thirty to forty-five minutes at a time. (R. at 655.) On May 28, 2013, Dr. Hill-Barlow reported that Plaintiff had undergone blood work that ruled out several possible chronic conditions. (R. at 654.) Dr. Hill-Barlow also noted that Plaintiff was seeing a new primary care doctor through Bon Secours who was located closer to Plaintiff's home. (R. at 654.)
On June 14, 2012, Plaintiff had an MRI of her cervical spine at VCU Health System to rule out hypertension and stenosis. (R. at 613.) The MR1 report stated that Plaintiff's cervical spine alignment was anatomical and the height of the vertebral bodies was maintained. (R. at 613.) No abnormal signals were detected in her spinal canal. (R. at 613.) Her C2-C3 disc was unremarkable. (R. at 613.) At C3-C4, there was mild right neural foraminal narrowing, but no spinal stenosis. (R. at 613.) At C4-05 and C5-C6, there were mild disc bulges without spinal stenosis or neural foraminal narrowing. (R. at 613.) At C6-C7, there was a disc bulge without spinal stenosis and with moderate bilateral neural foraminal narrowing. (R. at 614.) At C7-T1, there was mild bilateral neural foraminal narrowing but no spinal stenosis. (R. at 614.) At T2, the image ...