Stanhope v. Commissioner of Social Security Administration

          ORDER

          HONORABLE DEBORAH M. FINE UNITED STATES MAGISTRATE JUDGE.

         Plaintiff Stephanie Ann Stanhope (“Claimant”) appeals the Commissioner of Social Security Administration's decision to adopt the Administrative Law Judge's (ALJ's) ruling denying her applications for Disability Insurance Benefits under Title II of the Social Security Act and for Supplement Security Income under Title XVI of the Social Security Act. (Doc. 1, Doc. 15-3 at 20)^[1] Claimant argues that ALJ Ted W. Armbruster erred by: (1) assigning little weight to the opinions of John Porter, M.D., within a Physical Residual Functional Capacity Questionnaire dated May 2018; and (2) improperly rejecting Claimant's testimony regarding her pain, symptoms, and level of limitation. (Doc. 18 at 4-16)

         This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and with the parties' consent to Magistrate Judge jurisdiction pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the Court will affirm the Commissioner's decision.

         I. BACKGROUND

         A. Application and Social Security Administration review

         Claimant was 51 when she filed her applications for disability insurance benefits and supplemental security income on April 10, 2015, alleging a disability onset date of March 3, 2014. (Doc. 15-6 at 2-3, 9; Doc. 15-3 at 17) The state agency initially determined Claimant was not disabled in September 2015 (Doc. 15-4 at 2-12, 13-21), and again on reconsideration in March 2016 (Id. at 24-34, 35-45). After conducting a hearing on Claimant's applications on May 3, 2018 (Doc. 15-3 at 83-143), the ALJ filed a notice of an unfavorable decision on July19, 2018. (Id. at 14-29) Claimant then filed an appeal with the Appeals Council, which was denied by notice dated October 22, 2018. (Id. at 2-5) At that point, the Commissioner's decision became final. Brewes v. Comm'r of Soc. Sec. Admin., 682 F.3d 1157, 1162 (9^th Cir. 2012).

         B. Relevant medical treatment and imaging

         1. Maricopa Integrated Health Systems

         Claimant reported thoracic spine pain on May 31, 2014. (Doc. 15-8 at 5-14) X-rays indicated an unremarkable thoracic spine. (Id.) Her blood oxygenation (“SpO2”) was measured at 99%.^[2] (Id. at 7) On July 3, 2014, Claimant was seen for shortness of breath. (Id. at 17-25) Her physical examination documented normal range of motion, a normal psychiatric assessment, and SpO2 reading of 96%. (Id. at 20) In November 2014, Claimant complained of musculoskeletal pain and it was noted she took Tylenol and Ultram for it. (Id. at 27) Although she displayed diffuse mild wheezes and scattered rhonchi, her SpO2 was measured at 98%. (Id. at 28)

         In February 2017, Claimant complained of chest congestion and cough with shortness of breath. (Doc. 15-11 at 7) Her SpO2 reading was 95%. (Id. at 7) Claimant exhibited normal range of motion and normal mood and affect. (Id. at 8) In March 2017, it was reported that her cough had been treated with antibiotics with good results, but that her “illness came back.” (Id. at 12) Her SpO2 saturation level was 99%. (Id. at 14) She was noted to complain of pain in her back radiating down her legs, but her review of systems was negative for musculoskeletal issues. (Id.at 16-17) She exhibited a normal range of motion and normal mood and affect. (Id. at 17) She was not in any respiratory distress but had “wheezes.” (Id.) In April 2017, Claimant complained of memory loss and decreased concentration. (Id. at 33) Her SpO2 level was measured at 99%. (Id.) She was noted to have no pain, and demonstrated normal mood, affect, and behavior. (Id. at 33-34) During a sleep study, Claimant tested negative for obstructive sleep apnea. (Id. at 45)

         A pulmonary function test conducted in May 2017 identified a baseline SpO2 level of 94%. (Id. at 54) Claimant denied leg edema. (Id. at 70) She demonstrated a normal gait. (Id.at 72) Her musculoskeletal review was negative, with a normal range of motion. (Id. at 80) She exhibited normal mood and affect. (Id.) On May 15, 2017, Claimant complained of chronic back pain, but she displayed normal gait and station. (Id. at 84) In July 2017, Claimant's SpO2 was measured at 99%. (Doc. 15-9 at 10) She was encouraged to perform aerobic exercise and walking. (Id. at 11) No. lower extremity edema was observed, and Claimant's mood and affect were normal. (Id. at 15) On July 18, 2017, while being evaluated for bradycardia, Claimant reported no shortness of breath, no swelling in her hands or feet, and no dizziness, headaches, fatigue or pain. (Id. at 28) She reported memory issues such as forgetting where she placed her keys or wallet. (Id. at 29) She had a normal gait. (Id. at 30) On July 21, 2017, Claimant's physical examination indicated a SpO2 level of 96% and she reported hip pain. (Id. at 34) She exhibited a normal range of motion but displayed an anxious mood. (Id.) She was implanted with a pacemaker on September 13, 2017, to address symptoms of bradycardia. (Id. at 45) Two weeks post-implant, Claimant reported she felt better, slept better, had less anxiety, and thought her memory was improving. (Id. at 79)

         In October 2017, Claimant exhibited normal range of motion, normal behavior, mood, affect, thought content and judgment. (Id. at 89) In November 2017, her SpO2 measured 100% and she was reported to be in no pain. (Id. at 95) In February 2018, Claimant was seen at urgent care for a headache lasting one week. (Id. at 99) Her treatment notes included her reports of back pain radiating to her flanks and abdomen that worsened with walking. (Id. at 99) The review of symptoms indicated decreased range of motion and tenderness in her neck. (Id. at 101) Later in February 2018, Claimant complained about feeling overwhelmed, her desire to not leave home, and forgetfulness. (Id. at 106) She was seen in March 2018 for her complaint of memory changes. (Id. at 113-114) Her assessment indicated: normal attention span, concentration, and fund of knowledge; good immediate memory and recall of 2 out of 3 items after 5 minutes; a mini-mental examination score of 24/30, including loss of 4 points for counting numbers backwards; normal muscle tone; 5 of 5 muscle strength throughout; and normal gait and stance. (Id.) The doctor noted memory changes that he attributed to depression and anxiety. (Id. at 114) Claimant also reported pain in her back and neck at a level of 3 out of 10 and said she was using ibuprofen and baths to relieve her pain. (Id. at 115)

         On March 21, 2018, Claimant presented complaining of chest pain and shortness of breath on exertion and when lying on her back, but without edema, fainting or heart palpitations. (Id. at 119) Her SpO2 level was 98%. (Id.) She was nervous and anxious. (Id.) On March 27, 2018, Claimant's SpO2 was 99%. (Doc. 15-11 at 122) She displayed a normal range of motion in her musculoskeletal system and normal mood and affect. (Id.) On April 9, 2018, a functional status assessment indicated that Claimant reported she did not have serious difficulty walking or climbing stairs, or “difficulty doing errands alone such as visiting a doctor's office or shopping, ” or difficulty remembering, concentrating, or making decisions. (Doc. 15-12 at 20, 27)

         2. Sun Pain Management & Spine Specialists

         Claimant was seen for pain management in this practice between April 2017 and March 2018. (Doc. 15-8 at 52-84) In April 2017, Claimant complained of pain in her neck, back, and bilateral legs, knees, and shoulders. (Id. at 81) David Towns, M.D., recorded that Claimant said her pain had begun approximately 4 years previously, when she was still working, and that she had been prescribed a muscle relaxant, a narcotic, ibuprofen, and a nerve pain medication. (Id.) Claimant reported she had tried physical therapy two years before but “did not find it helpful” and was not interested in “injection therapy as she has heard bad things about it.” (Id.) Dr. Towns stated he would continue to educate her about the potential benefits of injection therapy. (Id.) Claimant declared her pain was aggravated by standing, sitting, walking, bending, stooping, twisting and lying on her side, but denied balance difficulty, anxiety or depression. (Id. at 82-83) Her physical examination indicated full range of motion and normal strength in her bilateral upper and lower extremities. (Id. at 83)

         In May 2017, she said she had balance issues and felt lightheaded first thing in the morning. (Id. at 79) She requested a walker because of this lightheadedness and because she had fallen. (Id.) She advised the doctor that her medications were helping to keep her “active and functional throughout the day” without side effects. (Id.) In August 2017, Claimant reported repeated falls. (Id. at 69-70) Her SpO2 level was 99%. (Id. at 66) In November 2017, Claimant complained of headaches and was told that her self-reported failure to consistently take medications could cause headaches. (Id. at 64) In December 2017, her provider noted Claimant had been out of town on a family emergency, had missed her appointment and was out of her medications. (Id. at 59) Her SpO2 saturation was 97%. (Id. at 60) Claimant's general appearance was observed to be “normal, pleasant, alert, well-hydrated/nourished, comfortable, in no acute distress, calm and relaxed, cooperative.” (Id. at 60) She had a normal neurologic exam, including normal gait. (Id.) In February 2018, Claimant was referred for physical therapy and was counseled to increase her activity level gradually and to consider proceeding with injection therapy. (Id. at 55-56) In March 2018, Claimant complained of bilateral wrist pain with bilateral Tinel's sign. (Id. at 53)

         Overall, while Claimant was treated at this practice, her psychological assessments consistently indicated good judgment and insight, good thought content, and that she was alert and oriented. (Id. at 52-84) She also consistently exhibited focal tenderness cervical/lumbar facet loading maneuvers, left knee tenderness but also a full range of motion, and full strength bilaterally in her upper and lower extremities. (Id.) She denied anxiety and depressed mood. (Id.)

         3. Terros, Inc.

         Claimant was first seen on April 5, 2018, for a core assessment and risk assessment of her complaints of depression and anxiety in order to obtain medication to reduce her symptoms. (Doc. 15-12 at 10-17) Claimant reported she would like to “be happier as she needs to take care of grandchildren and that requires a lot of work.” (Id. at 12) She stated she was prone to anxiety attacks and that she was often tired. (Id.) Impressions of her assessment included: unremarkable thought process; normal motor movement and gait; fair judgment; oriented to person, place and time; fair attention span and concentration; and depressed mood and tearful affect. (Id. at 15) She was prescribed medications for depression and anxiety. (Id. at 16)

         4. Medical records dated after ALJ's decision

         After her May 3, 2018, hearing, Claimant submitted medical records dated between June 11 and July 20, 2018. (Doc. 15-3 at 37-39, 51-57, 59-82) In its October 22, 2018, denial of Claimant's request for review of the ALJ's July 19, 2018 decision, the Appeals counsel reviewed this record and determined it “did not show a reasonable probability that it would change the outcome of the decision.” (Id. at 3) The evidence included Dr. Cory Bushmann's July 19, 2018, order for a motorized power scooter on a diagnosis of Claimant's gait instability (Id. at 39), and instructions for use of a medication intended to help patients quit smoking (Id. at 59-63). The records also included Claimant's office visits with the Banner Health Internal Medicine Office. On June 30, 2018, Claimant was seen for a “lobular mass on the left parapharyngeal space depression” in the neck, and for memory loss. (Id. at 64-67) She reported that her forgetfulness had “been getting worse within the past month to where her . . . daughter and her daughter's husband have moved in to help her take care of the house.”^[3] (Id. at 64) A mini-mental examination resulted in a score of 28 out of 30. (Id.) Her physical exam indicted an SpO2 level of 97%, normal range of motion and full strength in her musculoskeletal system with, no tenderness or swelling, and appropriate mood and affect. (Id. at 65) It was noted that Claimant's depression was “controlled” but that she “would like to see psychiatry to follow up with her medications.” (Id. at 66) On July 9, 2018, Claimant's SpO2 level measured 97%, she demonstrated appropriate mood and affect, and she exhibited normal range of motion and strength with no tenderness or swelling. (Id. at 73)

         The Appeals Council also advised Claimant that the medical records she had submitted that were dated between August 1 and October 12, 2018, and which post-dated the ALJ's July 19, 2018 decision, did not “impact the decision about whether [Claimant was] disabled beginning on or before July 19, 2018.” (Id. at 3) These records consisted of 13 pages of medical records including: a statement from a surgeon with Banner Health who planned to remove the mass in her neck in October 2018 (Id. at 36); impressions from a CT scan of Claimant's neck conducted in September 2018 (Id. at 40-41); records of an August 2018 office visit after Claimant apparently fainted (Id. at 42-50); and what appears to be a receipt for the delivery to Claimant of a motorized scooter (Id. at 58).

         5. Imaging

         On June 20, 2017, Claimant underwent a cervical spine MRI. (Doc. 15-8 at 85-86) The impressions from the imaging included: (1) spondylosis and disc bulging at the C3-4, C5-6, and C6-7 levels; (2) a congenitally small spinal cord canal without impingement on the cord; and (3) “left paramedian to lateral extending broad-based disc protrusion and osteophyte complex, C5-6 level without nerve root displacement or central canal narrowing[, and] [m]oderate left foraminal stenosis.” (Id. at 86)

         On June 20, 2017, imaging also was performed on Claimant's lumbar spine. (Id. at 88-89) The impressions on review of the MRI included: (1) “Grade 1 anterolisthesis of approximately 8 mm at the L5-S1 level with probable bilateral pars intra-articularis defects[ and] [d]isc uncovering with slight disc herniation in conjunction with mild facet arthropathy [which] results in moderate bilateral neural foraminal stenosis at this level[, along with] . . . mass effect on the ventral thecal sac without overt stenosis”; (2) mild to moderate spondylosis in the lower lumbar spine and slight herniation and desiccation and slight herniation of the L3-4 and L4-5 discs without significant central canal or neural foraminal stenosis; and (3) “slight gentle levoscoliosis of the lumbar spine.” (Id. at 89)

         Claimant's left knee was x-rayed on August 16, 2017 and was reviewed as “unremarkable.” (Id. at 87)

         On April 24, 2018, Claimant underwent an MRI of her brain. (Doc. 15-12 at 98) Findings included “mild chronic microvascular changes involving subcortical and periventricular white matter.” (Id.)

         Also on April 24, 2018, an MRI procedure of Claimant's left knee indicated “a complex tear of the medial meniscus with displacement of the anterior horn tear into the anterior aspect of the intercondylar notch.” (Id. at 99) Additionally, the imaging indicated “significant ...