United States District Court, D. New Jersey
OPINION, [DKT. NO. 1]
RENÉE MARIE BUMB UNITED STATES DISTRICT JUDGE.
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.
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).
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).
Coronary Artery Disease
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.)
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. (Id. at
Back Pain and Evaluations by Dr. Giamporcaro
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). The records also indicate that Plaintiff
was working full time. (See, e.g., Id. at 383).
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.
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).
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).
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
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).
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).
Consultative Examinations and State Agency
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).
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.)
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).
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.)
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
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 ...