United States District Court, N.D. New York
LAWRENCE E. KAHN, District Judge.
Plaintiff Cindy A. Winchell ("Plaintiff") has appealed after the Social Security Administration ("SSA") denied final review of an Administrative Law Judge ("ALJ") decision denying her application for disability benefits. Dkt. No. 1 ("Complaint"). For the reasons discussed below, the decision is affirmed.
A. Factual History
Plaintiff was born in 1959 and has a tenth-grade education. Dkt. No. 31 ("Record") at 27-29. Plaintiff first started working in 1977, but did not work from 1978 to 1994. R. at 87. She briefly worked again in 1995, 1996, and from 1999 to 2001. Id . At her job as a hand laborer at a paper company, where she worked intermittently from 1995 to 1999, Plaintiff sometimes carried objects weighing ten pounds. R. at 31. During her two-year employment at United Auto Supply from 1999 to 2001, Plaintiff drove a van and could lift up to twenty pounds a time. R. at 30. She quit due to back pain in March 2001. Id . From 2001 to 2006, the period for which Plaintiff is claiming disability benefits, she was not employed. Id . Plaintiff has provided medical records covering the periods from 1985 to 1999 and from 2010 to 2011, but none from 2001 to 2006. R. at 151-334.
On January 16, 1993, Plaintiff injured her back while moving furniture and went to the emergency room at Community-General Hospital ("CGH") in Syracuse, New York. R. at 189. A lumbosacral spinal x-ray was normal. R. at 190. On March 17, 1993, Plaintiff started to visit a physical therapist at the Health Science Center ("HSC") of Syracuse, NY, and rated her pain level as a nine out of ten, especially when bending, sitting, and rising. R. at 155. Within a month, Plaintiff alleged that the leg and back pain had increased. R. at 163. Physical Therapist Curt DeWeese recommended that Plaintiff work on posture and exercise. Id . On April 4, 1993, Plaintiff self-reported her functional status as bedrest, a condition worsened from the previous ten visits to Mr. DeWeese. R. at 169. However, an x-ray result from May 10, 1993, was negative and showed no muscle strength loss. R. at 183. At that time, Plaintiff was also still able to drive to the hospital. Id.
The only other extant medical records from before 2001 are emergency treatment records from 1985 to 1998. R. at 171-98. Plaintiff received emergency treatment from CGH for a fractured toe, chest wall pain, soft tissue injury, and lower back pain. R. at 187-98. But x-ray reports revealed nothing abnormal in the chest, thoracic spine, lumbosacral spine, cervical spine, or ribs, and there is no follow up examination documented in the record. Id . Specifically, on May 16, 1995, Plaintiff visited CGH again for back pain and the record shows a history of minimally bulging disc. R. at 180. While no bone or joint abnormality was present from the subsequent x-ray exam, Relafen was given. R. at 180-81. On August 2, 1995, Plaintiff went to CGH again for a contusion above her left eye from a fall at work. R. at 178. Even though she sustained an injury on the left side of her face, no neck or back pain resulted. Id . Plaintiff denied any problems with her eyes and she was treated with ice and Tylenol. R. at 176. On May 5, 1998, Plaintiff presented to CGH again for chest pain. R. at 172. The medical record shows that she was not in acute distress, though the "chest wall [was] slightly tender to palpation." Id . X-ray results showed clear lungs and no evidence of pneumonia or pulmonary edema. R. at 173.
In 2010, Plaintiff again sought medical attention. R. at 216. On August 3, 2010, Plaintiff visited Port Byron Community Health ("PBCH") for a diabetes check and for back pain. Id . Physician Assistant Jessica Hoff ("Hoff") diagnosed Plaintiff with diabetes mellitus type II, hypertension, and back pain. Id . On August 17, Plaintiff returned for a follow up with Hoff regarding back pain, and she was prescribed a muscle relaxant, Robaxin. R. at 214. During Plaintiff's next visit on September 21, 2010, Robaxin was stopped and Flexeril was prescribed instead. R. at 212. A magnetic resonance imaging ("MRI") examination from three days later showed minor degenerative bulging with no evidence of disc herniation at L5-S1, moderate facet hypertrophy with moderate right greater than left foraminal narrowing at L4-L5, and mild facet hypertrophy with foraminal narrowing. R. at 219. Physicians opined that there was no disc herniation or central spinal stenosis. Id.
On November 30, 2010, Plaintiff returned to PBCH for elevated back pain. R. at 254. Hoff examined Plaintiff and diagnosed her with diabetes mellitus type II, hypertension, depressive order, and liver disorder. R. at 254-55. On December 16, 2010, Plaintiff visited CNY Gastroenterology ("CNY") for the results of a hepatic function test and an ultrasound. R. at 204. The record from that visit indicates that Plaintiff's past medical history includes: diabetes mellitus, arthritis, back pain, hypertension, and hemorrhoids. Id . During this visit, medical tests identified Transaminase elevation with a aspartate transaminase ("ALT") score of eighty four and an alanine transaminase ("AST") of sixty-three. Id . Three small lesions were also identified in the left lobe of Plaintiff's liver. Id . However, Plaintiff's test results for hepatitis were negative. Id . At the time of this visit, Plaintiff was taking Flexeril, metformin, Actos, paroxetine, and daily vitamins. Id . Plaintiff was diagnosed with transaminase elevation, diabetes mellitus with elevated hernoglobin Alc, obesity, "fatty liver infiltration, and three subcentimeter lesions in the left lobe." R. at 205. The potential complications were nonalcoholic steatohepatitis ("NASH"), diabetes, and obesity, which required further observation of Plaintiff's liver and dietary discipline to lose weight. Id.
On October 26, 2010, Plaintiff visited PBCH for an initial medical health evaluation regarding anxiety in public spaces arising out of her abusive childhood. R. at 210. Deborah Cole-Wenderlich, a licensed social worker, diagnosed Plaintiff with posttraumatic stress disorder ("PTSD") and panic disorder with agoraphobia, mild agoraphobia avoidance, and moderate panic. Id . For treatment, Cole-Wenderlich planned to confer with Plaintiff's primary care doctor regarding possible medication. Id . However, the Record does not include any future documentation about consultation with Plaintiff's primary care doctor.
From November 2010, to August 2011, Plaintiff visited Cole-Wenderlich fourteen times. R. at 225-59. On November 9, 2010, Plaintiff came back for side effects from Vistaril, an anti-anxiety drug. R. at 258. Cole-Wenderlich discussed anxiety issues with Plaintiff and assisted her in recognizing the source of her anxiety. R. at 254-58. At the time, Plaintiff was taking Metformin, which treats type II diabetes, Naproxen, an anti-inflammatory drug for pain, Vistaril, and Paxil, a typical antidepressant drug. Id . On November 16, Plaintiff returned and worked with Ms. Cole-Wenderlich for more issues with past abuse memory. R. at 256. On this visit, Cole-Wenderlich only recommended Metformin and Paxil. Id . On December 28, Cole-Wenderlich and Plaintiff discussed Plaintiff's traumatic history and healthy behavior. R. at 252. Flexeril, Actos, a blood-sugar control drug, and Metoprolol Succinate, a blood pressure treatment drug, were added to the medication list. Id . On January 11, 2011, Plaintiff followed up with Cole-Wenderlich for family relationship issues. R. at 250. Plaintiff indicated a past history of abuse, and Ms. Cole-Wenderlich encouraged Plaintiff to talk with her husband about her feelings. Id . From February to August 2, 2011, the date of the last record, Plaintiff visited Cole-Wenderlich approximately twice a month for PTSD and other ongoing medical issues. R. 225-49. Cole-Wenderlich regularly encouraged Plaintiff to establish healthy relationships with family members. Id.
On January 27, 2011, Plaintiff returned to CNY for a follow-up visit. R. at 202. The computerized tomography ("CT") scan conducted on December 20, 2010, showed a cirrhotic liver with no apparent stigmata of liver disease or chronic liver disease. Id . The transaminase elevation result for Plaintiff decreased to a moderate level with an ALT of fifty seven and an AST of forty. Id . PA Mark Stever ("Stever") recommended upper endoscopy to ensure that there were no gastric antral vascular ectasia ("GAVE") or esophageal varices. On April 21, 2011, Plaintiff came back for a follow-up on transaminase elevation. R. at 199. Stever found that further complete blood count ("CBC") and coagulation studies did not suggest cirrhosis. Id . The liver function test ("LFT") result from April 18 also appeared normal within the reference range with an ALT of sixty eight and AST of thirty seven. Id . While Stever ruled out the possibility of autoimmune disease, metabolic liver disease, and hepatitis, Plaintiff's long history of diabetes and obesity indicated a a presumptive diagnosis of NASH. Id . The LFT showed normal range of ...