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SAPIENZA v. SHALALA

August 11, 1995

ROBERT SAPIENZA, Plaintiff, against DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES, Defendant.


The opinion of the court was delivered by: JOHN E. SPRIZZO

 SPRIZZO, D.J.,

 Plaintiff Robert Sapienza ("Sapienza") moves for judgment on the pleadings reversing a final decision of the Secretary of Health and Human Services (the "Secretary") denying his claim for disability insurance benefits, or, in the alternative for remand for further proceedings. For the reasons that follow, Sapienza's motion is denied in its entirety.

 BACKGROUND

 Sapienza worked as a fire fighter from 1977 through 1991. Transcript of Administrative Record ("Tr.") at 69. On November 3, 1990, Sapienza was injured while performing his duties as a fire fighter. Id. at 99. Due to those injuries, Sapienza ceased working as a fire fighter and took medical leave. Id. at 43. Approximately six weeks after the accident, with physician's approval, Sapienza returned to work at the fire department performing "light duty" tasks such as mopping and sweeping. Id. at 205, 296. He continued to receive his regular salary until December 1, 1991, when he retired from the fire department and began receiving pension disability benefits. Tr. at 44.

 Prior to applying for disability benefits with the Department of Health and Human Services ("HHS"), Sapienza consulted several doctors regarding his injury. Dr. Alverado examined Sapienza on November 4, 1990, the day following the accident. Tr. at 131. Dr. Alverado found that Sapienza had a full range of neck motion with some tenderness on full extension and rotation of the left upper extremity. Id. Dr. Alverado diagnosed Sapienza's condition as a neck sprain, put Sapienza on medical leave, id., and recommended two weeks of physical therapy, a cervical collar and over-the-counter pain relievers. Id. at 125-26.

 On November 20, 1990, Dr. Ira Neustadt, a neurologist, examined Sapienza and concluded that he had sustained mild head and neck trauma. Tr. at 291-92. Sapienza's neurological exam was within normal limits, and he was observed to be in no severe distress. Tr. 291. Sapienza exhibited a full range of motion of the neck in all directions. Id. Dr. Neustadt recommended, inter alia, hot packs, warm showers, light massage and the occasional use of anti-inflammatory agents. Id. at 292.

 On December 17, 1990, Dr. Peter Marchisello examined Sapienza, noting pain in the left shoulder and neck and numbness in the tips of the fingers of his left hand. Tr. at 203. Sapienza's neurological tests were negative with respect to motor power, sensation and reflexes. Id. at 204. He walked with a normal gait and showed a full range of motion of the cervical spine in both supine and standing positions. Id. Sapienza's circulation in his upper extremities was normal, and his hand strength appeared good. Id. Dr. Marchisello diagnosed Sapienza's condition as a cervical strain. Tr. at 203-05. Dr. Jacob Barie, the examining radiologist, and Dr. Marchisello concluded that an M.R.I. suggested the possibility of disc herniation. Id. at 295-96. Dr. Marchisello's December 31, 1990 report noted that Sapienza was depressed about his physical condition and the M.R.I. results. Id. at 201. Dr. Marchisello prescribed physical therapy, anti-inflammatory medication, and the use of a cervical collar. Id. at 202.

 On January 28, 1991, Dr. Valapet Sridaran, a specialist in physical medicine and rehabilitation, examined Sapienza. Tr. at 297-98. Sapienza appeared in no distress although he held his neck in a guarded manner. Id. at 297. Examination of the neck revealed normal curvature. On palpation, mild tenderness and para vertebral spasm appeared. Id. A neurological exam evidenced mild wasting but no gross weaknesses. Tr. at 297. Dr. Sridaran concluded that Sapienza suffered from mild acute radiculopathy. Id. at 298.

 Dr. Michael Kamalian examined Sapienza on three occasions in January and February 1991. Tr. at 287. Dr. Kamalian found that Sapienza was neurologically intact in all extremities and enjoyed full movement of his cervical spine. Id. Dr. Kamalian also concluded that Sapienza suffered from a herniated disc and recommended two weeks of physical therapy. Id.

 Sapienza filed an application for disability insurance benefits with the HHS on June 8, 1992. Tr. at 43-45. Thereafter, on June 30, 1992, Dr. Donald Phillips examined Sapienza in connection with his application for disability benefits. Id. at 304-06. His diagnosis confirmed the conclusions of Sapienza's other examining physicians. Id. In a report dated July 24, 1992, following an examination of Sapienza, Dr. Syed Moin noted evidence of disc herniation and indicated that Sapienza displayed no behavior suggestive of a significant psychiatric disorder. Id. at 308-13. Dr. Moin reported that Sapienza could stand or walk up to two hours a day and had no limitation on how long he could sit. Tr. at 312. Dr. Moin's report was inconclusive, however, on whether Sapienza could work absent further testing. Id. at 311-12. In a letter dated August 3, 1992, Dr. Thomas Lansen, a neurosurgeon, indicated that Sapienza was suffering from some degenerative disc changes, id. at 316, and recommended a cervical collar, anti-inflammatory agents and massage as treatments. Id.

 In a letter dated November 30, 1992, Dr. Nathaniel Shafer stated that he had reviewed the reports of Sapienza's previous examining physicians and had also performed his own examination. Tr. at 319-24. Dr. Shafer diagnosed severe sprain and strain of the cervical spine, radiculitis due to disc herniation and bulging, sprain and strain of the dorsal lumbar spine, contusion of the skull and cerebral concussion. Id. at 322. Dr. Shafer concluded that Sapienza was totally disabled and could not perform any duties as a fireman or any other occupation. Id. at 324.

 HHS initially denied Sapienza's application for disability benefits and again on reconsideration. Tr. at 55-57, 60-62. At Sapienza's request, a de novo hearing was held in front of an HHS Office of Administrative Appeals Administrative Law Judge ("ALJ") on April 7, 1993. Id. at 23-42. At the hearing Sapienza was represented by counsel, and voluminous medical evidence was presented recounting the treatment and evaluations described above. Id. Sapienza stated that his daily activities include walking his three children to the school bus, walking the dog, and taking walks around the neighborhood in the evening. Id. at 78, 95. Sapienza further described how he mows the grass, helps his wife with household tasks including house cleaning and caring for their children. Tr. at 78, 95. In addition, he stated that he drives a car, attends local car shows, and drives up to an hour into the city to spend time at the firehouse. Id. at 91-92.

 The ALJ issued an opinion on May 12, 1993, finding that Sapienza was not disabled within the meaning of Social Security Act §§ 216(i) and 223, as amended, and was therefore not entitled to benefits. Tr. at 15-19. The ALJ considered Sapienza's residual functional capacity, age, education, and work experience in reaching his conclusion. Id. at 19. The ALJ found that Sapienza had proven that he suffered from degenerative disc disease of the cervical spine with radiculopathy, which imposes restrictions on his ability to perform basic work-related functions, id. at 15, but ...


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