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Manchester v. Astrue

August 19, 2009

SARAH R. MANCHESTER, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Thomas J. McAvoy, Sr. U.S. District Judge

DECISION & ORDER

Sarah R. Manchester ("Plaintiff") brought this action pursuant to 42 U.S.C. § 1383(c)(3) to review a final determination of the Commissioner of Social Security ("the Commissioner") denying Plaintiff's application for Supplemental Security Income benefits ("SSI").

I. FACTS

A. Procedural History

Plaintiff filed an application for SSI on April 11, 2005 alleging disability since August 2, 2001. R. at 52.*fn1 On August 26, 2005, Plaintiff's application for SSI was denied. R. at 26. On October 5, 2005, Plaintiff made a timely request for a hearing before an Administrative Law Judge ("ALJ"). R. at 23.

On July 5, 2007, Plaintiff received a video hearing before ALJ Elizabeth Koennecke. R. at 254. After performing a de novo review of Plaintiff's disability claim, ALJ Koennecke issued a decision on September 21, 2007 finding that Plaintiff suffered from severe degenerative disc disease of the lumbar spine, but that this impairment did not preclude her from performing work that existed in significant numbers in the national economy. R. at 21. The ALJ concluded that Plaintiff did not suffer from a disability as defined in the Social Security Act ("the Act"), and was not eligible for SSI. R. at 21-22.

Plaintiff made a timely request to the Appeals Council for review of the ALJ's decision. R. at 10. On December 19, 2007, the Appeals Council denied Plaintiff's request for review, making the ALJ's ruling the Commissioner's final decision regarding Plaintiff's disability claim. R. at 5-7. Plaintiff now seeks review of the Commissioner's final decision.

B. Educational and Vocational History

Plaintiff was born on December 10, 1985. R. at 52. She graduated from high school in 2004 and attended college from 2004 to Fall 2006. R. at 259. Plaintiff has not engaged in and maintained sustained gainful activity and has no past relevant work. R. at 21, 259-63.

C. Medical History

1. Depression and Anxiety

On June 6, 2001, Plaintiff's parents admitted her to St. Lawrence Psychiatric Center ("SLPC") for mood swings, anger, irritability and suicidal ideations. R. at 127-28. Plaintiff reported a decreased energy level, crying spells, feelings of hopelessness, little motivation for leisure activities and guilt in relation to her brother's medical condition. R. at 129. Plaintiff requested admission to the inpatient unit of the Psychiatric Center and was subsequently evaluated by Dr. Mills, a child psychologist. Id. Plaintiff was estimated to be of average intellectual functioning with a current Global Assessment of Functioning ("GAF") score of 45. R. at 129. Her diagnosis indicated depressive disorder, chaotic and dysfunctional family system, lack of impulse control, discord with peers, physical abuse by her father and suicidal ideation. Id. Plaintiff was discharged on June 13, 2001. R. at 115.

Plaintiff continued outpatient treatment at SLPC. R. 115-19. A June 2002 progress update noted that Plaintiff showed mood stabilization, no suicidal thoughts and improvedfunctioning at school, with peers and within her family system. R. at 116. A progress update from June 2003 indicated that Plaintiff had participated in individual therapy and medication therapy over the preceding year. Id. A seasonal component to Plaintiff's depression was noted, but her moods continued to stabilize and her ability to cope with family and peer stressors improved. Id. An August 2004 discharge summary noted that over the course of Plaintiff's treatment at SLPC, she became less socially anxious and increasingly assertive. R. at 117.At the time of her discharge, Plaintiff denied significant depression or suicidal thoughts and was prescribed Zoloft. R. at 117-18. Plaintiff was discharged from outpatient treatment at SLPC on August 11, 2004 with a diagnosis of anxiety disorder and a GAF score of 70. R. at 115-19.

On March 9, 2006, Plaintiff presented to Dr. Gregory Healey, her primary care physician, complaining of depression. R. at 155. Plaintiff's symptoms included anhedonia, anxious moods, crying spells, decreased ability to concentrate, sadness and feelings of worthlessness. Id. Plaintiff felt that Effexor made her condition worse, but denied suicidal ideation. Id. Dr. Healey opined that Plaintiff was depressed and changed her medication from Effexor to Lexapro. R. at 156.

2. Physical Impairments

In early July 2003, Plaintiff was admitted to Fletcher Allen Health Care with back pain that became classic sciatica, "radiating down the posterior lateral aspect of the left leg and settling into the outside of the left foot." R. at 144. An MRI demonstrated a "sizable paracentral disc herniation at L5-S1 with displacement of the descending S1 nerve root." R. at 145. Plaintiff demonstrated positive straight leg raising on the left at about 30 degrees with no crossed straight leg raising or straight leg raising on the right. Id. On July 12, 2003, Dr. Todd Maugans performed an elective L5-S1 microdisectomy on Plaintiff. R. at 131. The operation was tolerated well without complication and Plaintiff was discharged on July 12, 2003. Id.

On July 28, 2003, Plaintiff underwent a follow-up examination with Dr. Maugans. R. at 143. Plaintiff reported that 95 percent of the pain in her left leg had subsided and that she had no dramatic pain in her lower back. Id. Plaintiff demonstrated straight leg raising on the left at about 75 degrees. Id. Plaintiff's neurological examination, including sensory, motor and reflex examination were normal. Id. Dr. Maugans opined that Plaintiff would likely have complete resolution of her radiculopathy symptoms. Id.

On June 8, 2004, Plaintiff attended a second follow-up visit with Dr. Maugans. R. at 141-42. Dr. Maugans noted that Plaintiff's pain level had decreased post-operatively from 10 out of 10 to 2-3 out of 10 on a visual analog pain scale. R. at 141. Plaintiff reported increased pain in her lower back after periods of prolonged sitting. Id. Dr. Maugans noted that Plaintiff complained of decreased flexibility but had no sensory changes or symptoms. Id. Plaintiff was using over-the-counter ibuprofen, but was not prescribed any chronic medications and was not undergoing any type of therapy. Id. Plaintiff's lumbar range of motion was diminished secondary to generalized muscular tightness and her lateral motion was normal. Id. Dr. Maugans found dramatic tightness and pain in Plaintiff's left hamstrings, but found no true straight leg raising. Id. A detailed sensory and motor examination of Plaintiff's lower extremities was normal with no evidence of active radiculopathy. Id. Dr. Maugans noted that there was no objective evidence of an active L5 radiculopathy, and opined that Plaintiff likely had low-grade inflamation residual in the nerve root. R. at 142. Plaintiff was prescribed ibuprofen and physical therapy and Dr. Maugans opined that Plaintiff would likely not require further medical attention. Id.

On March 7, 2005, Plaintiff presented to Canton-Potsdam Hospital with neck pain. R. at 202-06. A cervical spine examination showed no evidence of fracture or dislocation. R. at 189. Plaintiff's vertebral bodies and disc spaces were well maintained and her paraspinal soft tissues appeared normal. Id. On March 9, 2005, Plaintiff visited Dr. Healey, her primary care physician, for a follow-up examination. R. at 176. Plaintiff presented with moderate, constant and sharp pain. Id. Dr. Healey opined that Plaintiff had neck pain with a possible injury to the atlanto-axial ligaments.

R. at 177.

On April 26, 2005, Plaintiff presented to Dr. Healey with complaints of moderate and sharp pain of the thoracic and lumbar spines. R. at 174. Plaintiff was referred to Dr. Patrick Graupman, a neurologist with the Fletcher Allen Health Care Neurosurgery Division. R. at 198-99. Plaintiff informed Dr. Graupman that her back pain was around a 4 out of 10 on a visual analog pain scale and worsened with activity. R. at 198. Plaintiff had a mild positive straight leg raise test at about 45 degrees and a slightly decreased range of motion of the lumbar spine. R. at 199. An MRI showed a moderate central disk protrusion at the L5-S1 level and minimal to mild S1 nerve root impingement.

Id. Dr. Graupman prescribed physical therapy and ibuprofen and requested an MRI of the cervical thoracic spine and flexion/extension lumbar spine films. Id. An April 29, 2005 MRI indicated left paracentral disc herniation at the 5-1 level that appeared to compress and displace the descending left S1 nerve root. R. at 188. The 3-4 and 4-5 levels were within normal limits. Id.

On October 7, 2005, Plaintiff returned to Dr. Healey complaining of continued back pain that was exacerbated by bending. R. at 168. Neurovascular examination and muscle strength were normal, but Plaintiff's active range of motion was limited, with extension and flexion limited to 15 and 90 degrees respectively. R. at 169. Plaintiff presented to Dr. Healey with similar complaints on November 4, 2005 and March 7, 2006. R. at 167, 157.

Plaintiff underwent a nuclear medicine bone scan on March 13, 2006. R. at 187. No signs of any focal areas of abnormal activity were found. Id. On May 1, 2006, Plaintiff visited Dr. Graupman for a follow-up examination. R. at 196-97. Dr. Graupman reviewed an April 19, 2006 MRI and found that it showed no significant changes from Plaintiff's April 29, 2005 MRI. R. at 196. Despite Plaintiff's back pain, Dr. Graupman concluded that she had no "left-sided S1 radicular symptoms" and noted that he was "uneasy...saying that she needs a fusion at 5-1." Id. Dr. Graupman suggested "bilateral L5-S1 facet blocks with local anesthetic and steroid." Id.

3. Treating Source Reports

i. Dr. Todd Maugans

On June 8, 2004, Dr. Todd Maugans, Plaintiff's surgeon, completed a report detailing Plaintiff's condition and abilities for the New York State Office of Temporary and Disability Assistance Division of Disability Determinations. R. at 135-40. Dr. Maugans noted that Plaintiff's current pain levels were 2 out of 10 and 3 out of 10 in her back and left leg respectively. R. at 135. He opined that Plaintiff may suffer from chronic or recurrent pain issues. R. at 136. While Plaintiff suffered from tight back muscles, Dr. Maugans reported finding no objective evidence of neurological ...


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