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Robertson v. Commissioner of Social Security

United States District Court, D. New Jersey

June 26, 2017


          OPINION, [DKT. NO. 1]


         This matter comes before the Court on an appeal from a final administrative decision by the Commissioner of Social Security which denied benefits to Plaintiff Robert Lee Robertson (“Plaintiff”). (Administrative Record (“AR”) 7-9). On June 6, 2017, this Court conducted oral argument. For the reasons set forth below, the Commissioner's decision is affirmed.


         On October 19, 2011, Plaintiff filed an application for Social Security disability benefits under Title II and Title XVI of the Social Security Act. (AR 189-97). Plaintiff alleged a disability onset date of August 20, 2010 with underlying conditions of anxiety, heart problems, and Hepatitis C. (Id. at 110). Pursuant to the determination of the Administrative Law Judge (“ALJ”) currently being reviewed by this Court, Plaintiff meets the insured status requirements of the Social Security Act through March 31, 2016. (Id. at 12). The claim was initially denied on June 28, 2012. (Id. at 116). The claim was denied upon reconsideration on December 31, 2012. (Id. at 125). A hearing was held before an ALJ on April 22, 2014. (Id. at 28). On August 14, 2014, the ALJ entered an unfavorable decision. (Id. at 7-9). A request for review was denied by the Appeals Council on May 12, 2016. (Id. at 1-3).


         Plaintiff was born on April 9, 1962, making him 55 years old on the date of argument of this appeal. On the alleged onset date, Plaintiff was 48 years old, but he has since aged into the “closely approaching advanced age” category as of April 8, 2012. (AR 18).

         A. Treatment History

         i. Coronary Artery Disease

         As reflected in treatment records of Dr. Edward Wrobleski in a letter to Plaintiff's GP, Dr. Stephen J. Giamporcaro, in March of 2010, Plaintiff suffered an inferior wall myocardial infarction. (AR 554). “He was urgently taken to the cardiac catheterization laboratory where thrombectomy was performed on the right coronary artery. A Xience drug-eluting stent was inserted.” (Id.) Since that time, Dr. Wrobleski reports in his treatment notes, Plaintiff had been asymptomatic and had denied chest pain, shortness of breath, and dyspnea. (Id.) It was remarked that Plaintiff had a good activity level and had returned to working full time. (Id.)

         On December 1, 2010, Plaintiff was assessed for chest pain and stress imaging was generated. (Id. at 497). The testing indicated an impression that: (1) there was no evidence of stress-induced myocardial ischemia; (2) there was normal wall motion; and (3) the left ventricular ejection fraction was 60%. (Id.) On October 27, 2011, Plaintiff again was evaluated for chest pain, and the conclusion of the echocardiographic study was “normal.” (Id. at 485). Plaintiff had no reversible ischemic defect. (Id. at 484). A stress test indicated that there were no pharmacologically induced symptoms of chest pain and no stress-induced arrhythmias. (Id. at 486). In subsequent treatment in September 2012, Plaintiff reported that he was not suffering from chest pain, shortness of breath, or abdominal pain.[1] (Id. at 379).

         ii. Back Pain and Evaluations by Dr. Giamporcaro

         During the relevant period, Plaintiff has also sought treatment for back pain. The records, however, are inconsistent on the degree of Plaintiff's back problem. In July, October, and November 2011 and May 2012, Plaintiff had a normal musculoskeletal or back examination, (id. at 406, 409, 412, 396), although it was noted that he suffered from “back spasm” in some reports. (Id. at 410, 412). At other times, for instance in June, July, August, and September 2012, Plaintiff's record reflects diagnoses of “backache” or generalized complaints of back pain. (Id. at 379, 382, 384, 387, 390).[2] The records also indicate that Plaintiff was working full time. (See, e.g., Id. at 383).

         In April 2012, an x-ray examination of Plaintiff's spine revealed “a normal appearance to the vertebral bodies. The disc spaces [were] well preserved. There [was] no evidence of fracture, bone destruction or other abnormalities.” (Id. at 467). The overall impression was that Plaintiff had a normal lumbar spine. (Id.)

         In subsequently treating Plaintiff, Dr. Giamporcaro indicated that Plaintiff was totally disabled and attributed it - at least in part - to Plaintiff's back, diagnosing Plaintiff with coronary artery disease, diabetes mellitus, and a herniated lumbar disc. (Id. at 556-57). He remarked that Plaintiff had been disabled from February 20, 2013 through February 20, 2014. (Id.) In April 2014, Dr. Giamporcaro noted that Plaintiff had diagnoses of coronary artery disease, herniated disc, and depression. (Id. at 856). He remarked that as a result of Plaintiff's symptoms, he was severely limited and assessed him with significant limitations, including that he would be absent from work more than three times monthly and could not deal with work related stress. (Id. at 856-61).

         An MRI of Plaintiff's lumbar spine in February 2013 revealed diffuse degenerative disc disease most pronounced at ¶ 5-SI with broad-based desiccated disc bulge and a superimposed left paracentral disc protrusion effacing the left lateral recess causing central canal and neural foraminal narrowing, and less severe degenerative disc narrowing and facet joint disease at ¶ 3-L4 and L4-L5. (Id. at 580).

         iii. Bipolar Disorder

         Although some medical records from 2011 and 2012 seem to indicate that Plaintiff had a “normal” mental status, (id. at 393, 399, 404, 412), in February 2013, Plaintiff began treatment at Crossroads for mental health issues. A treatment note from Crossroads notes that he was referred there from a recovery program “due to an increase in depression, anxiety, feelings of hopelessness, [history] of trauma - seeing friend shot. [History] of criminal activity. Desired to have mood stabilized, [decrease] any feelings of depression[.]” (Id. at 829). At Crossroads, Plaintiff was treated by Anne Albiez, APN. (Id. at 815). In associated records, it was noted that Plaintiff suffered from bipolar II disorder and opiate abuse. (Id. at 817). In Plaintiff's intake notice dated July 3, 2013, it was noted that Plaintiff was “[v]ery depressed with difficulty sleeping and isolation. Feelings of hopelessness and anxiety.” (Id. at 822). Similarly, in an assessment of Plaintiff's risk factors, it was noted that Plaintiff suffered risk factors of suicidal ideation, substance use, anxiety, physical complaint/medical issues, and insomnia. (Id. at 825). However, that same evaluation noted that Plaintiff's appearance and behavior were appropriate, he was cooperative and oriented with no thought disorder and goal directed and logical thought processes. (Id.). Plaintiff also was noted to be of average intellect, normal concentration, and fair insight/judgment. Plaintiff had immediate, recent, and remote memory intact. (Id.) His Global Assessment of Function (“GAF”) score was noted to be a 45.[3] (Id.)

         On December 5, 2013, Ms. Albiez filled out a mental impairment questionnaire which assessed Plaintiff's residual functioning ability. That evaluation determined Plaintiff's GAF score was 55, with a highest GAF of 60 in the past year. (Id. at 850). At that time, she observed that Plaintiff had a stable mood with medication and exhibited no oddities of thought, perception, speech, or behavior. Plaintiff was not socially withdrawn, was without delusions or hallucinations, and was without difficulty concentrating. (Id. at 850-51). At that time it was noted that Plaintiff's prognosis was fair and most of Plaintiff's psychotic symptoms were related to drug use. (Id. at 852-53). It was also noted that Plaintiff would be absent from a job more than three times a month with his current impairments. (Id. at 853).

         An April 7, 2014 evaluation by Ms. Albiez determined that Plaintiff would be markedly limited in his ability to remember locations and work-like procedures, the ability to understand and remember detailed instructions, the ability to carry out detailed instructions, the ability to maintain attention and concentration for extended periods, the ability to work in coordination with or proximity to others without being unduly distracted by them, and the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. (Id. at 846-849).

         iv. Consultative Examinations and State Agency Assessments

         Plaintiff has undergone a number of consultative examinations. In an April 16, 2012 consultative examination by Dr. P. Lawrence Seifer, Plaintiff complained of severe depression, anxiety, and low energy. At the time, Plaintiff was homeless. (Id. at 340). With regard to the activities of daily living, Plaintiff reported to Dr. Seifer that he had trouble shopping, using public transportation, and interacting with people. (Id. at 341). Plaintiff was also observed to have a normal gait and posture. His dress and hygiene appeared good. (Id.) It was also reported that Plaintiff could do a little housework, follow simple instructions, and function independently. (Id.) Plaintiff was observed to have “moderate/severe” limitations due to a combination of physical and mental states, including major depressive disorder with psychotic features and panic disorder without agoraphobia. (Id. at 342).

         In June 2012, Dr. C. Ivan Gordan evaluated Plaintiff. (Id. at 344). At that time, Plaintiff's chief complaint was depression dating back to 2004, along with Hepatitis C, gastroesophageal reflux disease (“GERD”), and hypertension. (Id.) Plaintiff was not working at the time. (Id. at 345). A physical examination showed full range of motion in all joints, with an intact muscle system. (Id.) Dr. Gordon's impressions were that Plaintiff suffered from reactive depression, not currently stabilized; postmyocardial infarction; GERD (controlled with medication); hypertension (controlled with medication); and borderline diabetes. (Id.)

         On June 26, 2012, Dr. Morris Feman completed an assessment of Plaintiff's residual functional capacity (“RFC”) and determined that Plaintiff had no postural, manipulative, visual, communicative, or environmental limitations. (Id. at 69-70). Dr. Feman determined Plaintiff could occasionally lift/carry 20 pounds, could frequently lift or carry 10 pounds, could stand or walk for about 6 hours in an 8-hour workday, could sit for a total of six hours in an 8-hour workday, and could do an unlimited amount of pushing, and/or pulling. (Id. at 70). On December 12, 2013, Dr. Nancy Simpkins agreed on reconsideration. (Id. at 100).

         Plaintiff's mental RFC was also assessed by state agency professionals. On June 7, 2012, Dr. Amy Brams reviewed Plaintiff's medical records and completed a case analysis. Dr. Brams indicated that Plaintiff had mild restriction of daily living activities, moderate difficulty maintaining social functioning, moderate difficulties maintaining concentration, and no repeated episodes of decompensation. (Id. at 68). In completing a mental RFC assessment for Plaintiff, Dr. Brams concluded that Plaintiff was not significantly limited in his ability to carry out very short and simple instructions, his ability to sustain an ordinary routine without special supervision, and his ability to work in coordination with or in proximity to others without being distracted by them. (Id. at 71). Plaintiff was moderately limited in his abilities to: maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerances, make simple work-related decisions, and complete a normal workday and workweek without interruptions from psychologically based symptoms, and perform at a consistent pace without an unreasonable number and length of rest periods. (Id.)

         B. Testimony

         i. Plaintiff's Testimony

         Plaintiff testified in his hearing before the ALJ. (Id. at 28). In detailing his work history, Plaintiff testified that he previously worked as a Bellman/Valet from 1999 through 2010. (Id. at 30). During that same timeframe, Plaintiff also worked in medical transport and worked as a cashier. (Id. at 30-31). Plaintiff last worked in 2011. (Id. at 32). At the hearing, Plaintiff testified that he did not think he would be able to return to his previous work because of the lifting required and the fact that his back “locks up.” (Id. at 45).

         As far as Plaintiff's medical conditions, he first testified about problems with his back. (Id. at 33). He was using a cane during the hearing, which Plaintiff testified was prescribed by a doctor. (Id.) Plaintiff testified that he has “messed discs in [his] back. I have a lot of arthritis. I get real, real bad muscle spasms and my back locks up on me.” (Id.) Plaintiff testified that Dr. Giamporcaro had been been treating him for his back and treating him more generally for 25 years. (Id. at 34). Plaintiff testified that Dr. Giamporcaro had been ...

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