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Bennett v. Saul

United States District Court, District of Columbia

October 28, 2019

ANDREW SAUL[1], Defendant


          Colleen Kollar-Kotelly United States District Judge.

         Plaintiff Cloteal Bennett brings this action seeking review of the final administrative decision by Defendant Andrew Saul, in his official capacity as Commissioner of Social Security (the “Commissioner”), denying Plaintiff's claim for Disability Insurance Benefits (“DIB”) pursuant to Title II of the Social Security Act. 42 U.S.C. §§401-433. Pending before the Court are Plaintiff's Motion for Judgment of Reversal and Defendant's Motion for Judgment of Affirmance. After reviewing the parties' briefs, [2] the administrative record, and the relevant case law, the Court shall DENY Plaintiff's [19] Motion for Judgment of Reversal and shall GRANT Defendant's [20] Motion for Judgment of Affirmance. For the reasons that follow, the Commissioner's decision below is affirmed.

         I. BACKGROUND

         A. Legal Framework and Procedural History

         Plaintiff petitioned the Social Security Administration for DIB pursuant to Title II of the Social Security Act on March 13, 2014. See Pl.'s Mot, ECF No. 19, 1. To qualify for DIB, a claimant must demonstrate an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, ” coupled with an inability to “engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(1)-(2). By satisfying both conditions, a claimant is “disabled” for purposes of the Social Security Act. To decide whether a claimant has proven she is disabled, the ALJ must use a five-step sequential analysis. 20 C.F.R. §§ 404.1520(4), 416.920(4). The steps require a determination of (1) current work activity; (2) severity of the impairment; (3) whether the impairment meets or equals a listed impairment; (4) if the impairment prevents claimant from doing past work; and (5) if the impairment prevents claimant from doing other work upon consideration of the claimant's residual functional capacity (“RFC”). Id.

         Plaintiff was born on February 14, 1968. AR 29. Prior to alleging disability, Plaintiff worked as a Metro Special Police Officer until 2007. Id. Plaintiff was injured on the job in 2000 when she caught her leg under a chair and fell against a wall. AR 393. In her application for DIB, Plaintiff alleged that her disabilities, which stemmed from her 2000 injury, included lumbar strain and herniated disc, cervical strain, right wrist pain and fracture, and obesity. AR 245-46, 302, 48-49.

         Plaintiff's claims were initially denied on August 1, 2014 and on reconsideration on January 2, 2015. AR 95, 104. Following these denials, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). That hearing occurred on September 21, 2017, where Plaintiff and an impartial vocational expert testified. AR 38-66.[3] Plaintiff was represented by counsel. At the hearing, Plaintiff amended the date for the alleged onset of her disability to April 1, 2015. AR 47. In a decision dated October 3, 2017, the ALJ denied Plaintiff's requested benefits. AR 19-31. Plaintiff sought review of this decision by the Appeals Council. However, the Appeals Council denied Plaintiff's request for review, and the ALJ's decision became the final decision of the Commissioner. AR 6-10.

         In issuing the controlling decision denying Plaintiff DIB, the ALJ made the following determinations. At Step One, the ALJ noted that Plaintiff did not engage in substantial gainful activity during the period from her amended onset date, April 1, 2015, through her date of last insured, March 31, 2016. AR 24. At Step Two, the ALJ determined that the medical evidence established that Plaintiff suffered from “the following severe impairments: degenerative disc disease of the lumbar spine (“DDD”) and degenerative joint disease of the left knee (“DJD”).” Id. The ALJ did not find Plaintiff's obesity to be a severe impairment but considered obesity in the context of the decision. AR 24-25. At Step Three, the ALJ determined that Plaintiff “did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.” AR 25. The ALJ found that Plaintiff's physical impairments did not meet the requirements of the impairments listed. Additionally, the ALJ found that Plaintiff did not demonstrate the required degree of difficulty in ambulating. Id.

         As is most relevant to this Memorandum Opinion, at Step Four, the ALJ found that Plaintiff “had the residual functional capacity (hereafter “RFC”) to perform light work as defined in 20 CFR 404.1567(b) except no climbing of ladders, ropes, or scaffolds; occasional climbing of stairs or ramps; occasional stooping, crouching, crawling or kneeling.” AR 26. Based on Plaintiff's RFC, the ALJ determined that Plaintiff was capable of performing her past relevant work as a Special Police Officer. AR 29. At Step Five, considering Plaintiff's age, education, work experience, and RFC, the ALJ determined that Plaintiff was also able to do other work. Crediting the vocational expert's testimony, the ALJ found that Plaintiff could perform the requirements of representative occupations such as machine tender, packer and packaging worker, and grading/sorting worker, which are available in the national economy for an individual similarly situated to Plaintiff. AR 29-30.

         Based on this five-step analysis, the ALJ concluded that Plaintiff “was not under a disability, as defined in the Social Security Act, at any time from April 1, 20[1]5, the amended onset date, through March 31, 2016, the date last insured (20 CFR 404.1520(f)).” AR 31. As was previously stated, Plaintiff sought review of this decision by the Appeals Council. AR 6-11. On April 30, 2018, the Appeals Council upheld the decision of the ALJ, finding no basis for changing the ALJ's decision. AR 6. Having exhausted her administrative remedies, Plaintiff has brought this action seeking reversal of her disability denial. See generally Pl.'s Mot, ECF No. 19.

         B. Evidence Contained in the Administrative Record

         The ALJ evaluated Plaintiff's condition based on evidence including various medical records and the testimony of Plaintiff and the vocational expert during the administrative hearing in this case. The Court recounts below the most relevant portions of the administrative record.

         1. Physical Health Records

         a. Drs. Phillips & Green, M.D. Partnership

         Plaintiff was initially injured in 2000 when, working as a Special Police Officer, Plaintiff caught her leg under a chair and fell. From approximately 2008 through 2010, Plaintiff treated with orthopedist Drs. Jeffery Phillips, M.D. and Simon Green, M.D.

         Throughout 2008, the doctors noted that Plaintiff had tenderness and spasms in her lumbar region. Plaintiff also had restricted range of motion in her lumbar area. However, Plaintiff was found to be neurologically intact in her lower extremities. Plaintiff was noted to walk slowly but was found to have an antalgic gait or limp only occasionally. Plaintiff began epidural steroids for her pain. AR 522-537.

         In December 2008, medical notes from Dr. Phillips indicate that Plaintiff had a satisfactory gait but continued to have tenderness and muscle spasms in the mid and low lumbar region. Plaintiff's range of motion in her back was restricted with pain and muscle spasms. The doctor recommended that Plaintiff be considered for light duty type work where she is “not on her feet all day; not doing any significant standing, walking or climbing; patient could sit and watch monitors and/or do desk work but cannot work doing routine work as a special police officer.” AR 375.

         Further notes throughout 2009 continue to indicate that Plaintiff had tenderness in her mid to low lumbar region with moderate muscle spasms. Plaintiff's range of motion continued to be restricted. But, Plaintiff was neurologically intact in her lower extremities and was found to have a satisfactory gait. During this time, Plaintiff was given epidural steroids for her pain. AR 508-520.

         Notes from March 2010 indicate that, when standing, Plaintiff bore weight equally on both feet but walked with a right antalgic gait. She also had tenderness in the mid and low lumbar region and continued to have muscle spasms. Plaintiff had intact reflexes and motor power. The doctor indicated that Plaintiff was discharged from active care as there was nothing further that could be done. He stated that Plaintiff could work in a “strictly sedentary position and should not be working as an active special police office; this is on a permanent basis.” AR 505-06.

         In September 2014, Plaintiff returned to the clinic of Drs. Phillips and Green. Dr. Phillips determined that Plaintiff bore weight equally on both feet and ambulated was a mild right antalgic gait. She could stand on her heels and toes without difficulty. She had tenderness from the mid to low lumbar region. Straight leg raises caused Plaintiff back pain, but her reflexes, sensation, and motor power were intact. The doctor indicated that Plaintiff's examination had not changed significantly since 2010 and that there was nothing he could do for her except recommend pain management. AR 504.

         In November 2016, Plaintiff again returned to the clinic following a car accident, which is further discussed below. AR 490-92. Plaintiff's chief complaints were neck pain, mid and lower back pain, headaches, and difficulty sleeping. AR 490. A physical examination revealed neck spasms, tenderness, and limited range of motion. AR 491. Additionally, Plaintiff stood erect bearing equal weight on both lower extremities but walked with a slight limp. Plaintiff was able to walk on her heels and toes. Plaintiff had tenderness and spasms in her back. She had a limited range of motion but negative straight leg tests, intact muscle power, and no significant atrophy. Id. X-rays showed no fractures or dislocations. Id. Plaintiff was diagnosed with a neck and lower back strain. AR 492. The doctor recommended physical therapy. Id. Plaintiff was listed as not fit for working duty. Id.

         Plaintiff returned approximately one month later for a re-evaluation. AR 489. Plaintiff reported continued neck and low back pain. She also indicated swelling in her right wrist due to the car accident. On physical examination, Plaintiff's neck was tender and had spasms and restricted range of motion. Plaintiff's back was tender with mild spasms but had improved since the prior visit. There was still mild decreased motion, which had also improved since the prior visit. Plaintiff was neurologically intact in her lower and upper extremities. Plaintiff's wrist was tender and the range of motion was restricted with some weakness. However, there was no swelling. Id. The doctor recommended continued therapy.

         Plaintiff continued to return for check-ups in early 2017. AR 583-86. On her visit in January 2017, Plaintiff reported that she was still having wrist and neck pain but that her back pain had improved to the pre-accident state. AR 586. An examination revealed tenderness and restricted motion in Plaintiff's neck and wrist. Id. The doctor also ordered an MRI of Plaintiff's wrist which revealed marrow edema and a small volar ganglio but no fracture line. AR 584. In February 2017, the doctor indicated that Plaintiff was unable to work pending Plaintiff's next evaluation. AR 583, 587.

         b. Dr. Joshua Ammerman

         From 2006 to 2010, Plaintiff treated with Dr. Joshua Ammerman, M.D. for lower back pain and lower extremity radiculopathy resulting from her 2000 workplace injury. Records from October 2006 indicate that Plaintiff had tenderness and mild restriction of motion in her lower lumbar. However, she had an unremarkable gait and intact reflexes, could stand on her heels and toes, and demonstrated equivocal straight leg raising. AR 393. A lumbar MRI from December 2007 showed small central disc herniation with no evidence of nerve root impingement. AR 376. Based on the MRI, it was determined that Plaintiff was not a candidate for surgery and instead used pain management, such as epidural blocks and a TENS unit. AR 400, 373, 389, 383.

         In October 2008, the doctor noted that Plaintiff continued to have back and bilateral leg pain and walked with a limp. The doctor recommended continued pain management. AR 401. Notes from early 2009 indicate that Plaintiff walked with a pronounced limp and had significant restriction of the lumbar range of motion. She was restricted to sedentary work. But, Plaintiff still had full strength in her lower extremities. AR 402. Later in 2009, notes indicated that Plaintiff was doing reasonably well with pain management. The doctor determined that Plaintiff had an improved limp but continued to have restricted lumbar range of motion. AR 403. In August 2010, medical notes stated that Plaintiff continued to walk with a mild limp and have a restricted lumbar range of motion. She also had discomfort in her hips. She was continuing with pain management and had used Lidoderm patches with good results. AR 392. Plaintiff was instructed to return on an as-needed basis.

         Plaintiff returned for a follow-up 2012. Plaintiff indicated that she had back and lower extremity pain and tingling. She reported numbness in her toes. The doctor noted that motor testing was full in the lower extremities, straight leg raising was negative and there was moderate restriction of lumbar range of motion. AR 391.

         c. Dr. Rebecca Gliksman

         In July 2014, the Division of Disability Determination sent Plaintiff for an examination in connection with her disability claim. AR 404-08. Plaintiff had a consultative examine with Dr. Rebecca Gliksman, M.D. Plaintiff presented with back pain caused by her 2000 workplace injury. Plaintiff reported a worsening of her pain over time. Plaintiff also reported increased numbness when sitting for an extended period of time. Plaintiff further stated that she had difficulty walking, climbing stairs, and sitting. AR 404. In examining Plaintiff, the doctor stated that Plaintiff appeared to be in acute distress due to pain. Plaintiff initially walked with a slight limp, but her gait normalized. She could squat to 1/3. She did not require an assistive device for walking. AR 406. Plaintiff was diagnosed with lumbar pain with radiation and received a fair to guarded prognosis. AR 407. The doctor found a moderate limitation in walking, climbing, lifting and carrying due to lower back pain with limited range of motion and decreased lower extremity strength. Id.

         d. Dr. ...

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