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Roberts-Learch v. Commissioner of Social Security

United States District Court, D. New Jersey

January 31, 2019

HEATHER C. ROBERTS-LERCH, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          Adrienne Freya Jarvis, Esq. Attorney for Plaintiff

          Eda Giusti, Special Assistant U.S. Attorney SOCIAL SECURITY ADMINISTRATION OFFICE OF THE GENERAL COUNSEL Attorney for Defendant

          OPINION

          JEROME B. SIMANDLE U.S. DISTRICT JUDGE

         I. INTRODUCTION

         This matter comes before the Court pursuant to 42 U.S.C § 405(g) for review of the final decision of the Commissioner of the Social Security Administration (“SSA”) denying the application of Plaintiff Heather C. Roberts-Lerch (“Plaintiff”) for Social Security Disability Insurance (“SSDI”) benefits under Title II of the Social Security Act, 42 U.S.C. § 401 et seq. Plaintiff, who suffers from reflex sympathetic dystrophy (“RSD”)/chronic regional pain syndrome (“CRPS”) on the right side, rheumatoid arthritis, and other conditions, was denied benefits for the period of disability from March 11, 2011, the alleged onset date of disability, to November 3, 2015, the date on which the Administrative Law Judge (“ALJ”) issued a written decision.

         In the pending appeal, Plaintiff contends that the ALJ's decision must be reversed and remanded on four grounds. To that end, Plaintiff argues that the ALJ erred by: (1) selectively rejecting the opinions of certain medical sources of record; (2) crafting a Residual Functional Capacity (“RFC”) that was not supported by substantial evidence; (3) finding Plaintiff's allegations not entirely credible; and (4) failing to establish that there is other work in the national economy that Plaintiff could perform. For the reasons that follow, the Court will affirm the ALJ's decision.

         II. BACKGROUND

         A. Procedural History

         Plaintiff protectively filed an application for SSDI benefits on February 5, 2013, alleging a disability as of March 11, 2011. (R. at 80, 107, 166-72, 184, 188.) The SSA denied Plaintiff's claim on June 14, 2013. (R. at 109-13.) Plaintiff's claim was again denied upon reconsideration on September 12, 2013. (R. at 115-20.) A hearing was held before ALJ Marguerite Toland on May 12, 2015. (R. at 36-79.) ALJ Toland issued her opinion on November 3, 2015, denying benefits. (R. at 13-29.) On April 6, 2017, the Appeals Counsel denied Plaintiff's request for review. (R. at 1-5.) This appeal timely follows.

         B. Personal and Medical History

          Plaintiff was 37 years old on the alleged disability onset date and 41 years old at the time of her hearing before the ALJ.[1](R. at 43, 80.) She graduated from college and earned a master's degree in Elementary Education. (R. at 45, 189.) Between 1996 and March 11, 2011, Plaintiff primarily worked as a kindergarten and elementary school teacher for the Willingboro Board of Education. (R. at 189, 195.) After leaving her job in March 2011, Plaintiff has never tried to go back to work as a teacher. (R. at 43.) Since 2008, Plaintiff has also been the joint owner of a consulting business with her husband, for which her duties include tracking emails and writing/depositing checks.[2] (R. at 47.) She was insured for purposes of SSDI benefits through September of 2017. (R. at 179.)

         Plaintiff was diagnosed with descending Guillain-Barre syndrome in February 2008. (R. at 259.) On June 15, 2008, Plaintiff treated with Dr. Robert J. Schwartzman, M.D., at Hahnemann University Hospital for “pain in my right arm.” (Id.) Plaintiff also complained of reduced visual activity, numbness and tingling in the face and body, and pain in her left arm and both legs. (Id.) Dr. Schwartzman observed that Plaintiff “responded well to plasmapheresis, ” but noted clinical signs of right facial drop, reduced strength of the right upper extremity of 3-4/5, positive Tinel points on the right, positive allodynia[3] in the right arm and leg, mechanical and static allodynia, dynamic allodynia, and some mild neurogenic edema in the right hand, livedo reticularis, [4]and low hemoglobin. (R. at 260.) Plaintiff was treated with intravenous immunoglobulin infusions and cortisone. (R. at 259-61.)

         For the next few years, Plaintiff continued to treat with Dr. Schwartzman for her pain-related symptoms. (R. at 263-64, 293-95.) On July 23, 2010, Dr. Schwartzman recommended “Botox injection[s] as needed” due to Plaintiff's “severe chronic pains and inability to function daily.” (R. at 292.)

         Plaintiff left her job as a teacher on March 11, 2011. (R. at 18.) At the time, Plaintiff was pregnant and unable to take any medicines for her RSD, including ketamine. (R. at 269.) Medical records indicate that, as of March 21, 2011, she was “on disability for pregnancy and plans add[itional] year of disability after pregnancy from Neuro.” (R. at 270.)

         On March 14, 2011, Plaintiff reported “[s]evere pain in right brachial plexus distributions, ” which “radiates across trapezius ridge, down the medial scapular border and primarily into middle trunk posterior cord distributions. This encompasses the triceps, dorsal forearm, [and] dorsal portion of her hand.” (R. at 290.) Plaintiff also had “some pain in upper thigh, hip and buttocks, ” which she described as “occasionally sharp, mostly constant dull pain with some burning.” (Id.) Dr. Schwartzman noted that Plaintiff “[j]ust finished teaching for this year and should be on disability for the next year while being treated and taking care of . . . her child at the same time.” (R. at 290.) Among other things, he diagnosed Plaintiff with RSD/CRPS on the right side. (R. at 289, 291.)

         In April 2011, Plaintiff unfortunately had a miscarriage. (R. at 272-74.) Thereafter, Plaintiff resumed ketamine infusions every three months (R. at R. at 272-73, 464-516), although there is “a gap in the record from May 2011 to February 2013” during which time Plaintiff did not receive ketamine infusions, as the ALJ noted. (R. at 24.)

         On April 3, 2012, Dr. Schwartzman completed a Capacity Questionnaire in conjunction with Plaintiff's application for private disability benefits to Prudential, in which he opined that Plaintiff did not have the capacity to work an eight-hour workday and that he was unable to determine when she could return to fulltime work. (R. at 577-78.)

         On June 18, 2012, Dr. Schwartzman reexamined Plaintiff for complaints of severe right arm pain. (R. at 284.) Upon examination, he noted that Plaintiff was undergoing treatment for her thyroid and “[w]hen this is complete her pain situation will be reassessed.” (R. at 286.) Dr. Schwartzman subsequently administered a right cervical plexus block. (R. at 495-96.)

         On December 4, 2012, Dr. Joshua Alpers, M.D., reviewed Plaintiff's claim for disability benefits at the request of Prudential, and opined as follows:

The diagnosis of CRPS is adequately supported as detailed in the following recommendations. Individuals with CRPS are in constant pain though are only incapacitated during periods of severe pain. As such, she is capable of maintaining employment in a sedentary capacity between these periods of severe pain. However, given the unpredictable nature of her pain and the widespread distribution of symptoms, it appears likely that this would result in a significant reduction in her work hours and would likely prevent her from maintaining gainful employment. Quantification of functional impairment in association with pain is challenging due to the inherent self[-]reported nature of pain. However, as evidenced by her apparent compliance with treatment plans (as reported by Dr. Schwartzman) to include ketamine infusions, she appears to have made appropriate efforts to improve her level of functioning. The recommendations by Dr. Schwartzman in April 2012 are appropriate, effectively restricting [Plaintiff] to a sedentary occupation on a part-time capacity. This would include only occasional standing/walking with sitting up to four hours per day. Occasional reaching at desk level and handling are supported although activities including balance should be avoided as well as a lift/carry restriction of no more than 10 pounds.

(R. at 432-33.)

         On April 23, 2013, Dr. Schwartzman completed a Medical Examination by Treating Physician form for the State of New Jersey, wherein he opined that Plaintiff was “totally and permanently disabled and no longer able to perform his or her job duties and/or any other job” because she was “unable to use right hand to write on board, unable to stand for long periods of time. Needs to take breaks and being a teacher she is unable to.” (R. at 581-82.) He also checked boxes indicating that Plaintiff's disability was progressive and that there was not a possibility her disability might improve. (R. at 582.)

         On May 27, 2013, Dr. Francky Merlin, M.D., examined Plaintiff. (R. at 327-29.) On physical examination, Plaintiff's motor function was 4/5 in the right leg and 5/5 in her other extremities. (R. at 328.) Dr. Merlin diagnosed Plaintiff with RSD and a history of rheumatoid arthritis, and opined that Plaintiff “is able to sit, stand, walk, crouch, hear, and speak.” (R. at 329.)

         On September 23, 2013, Plaintiff was examined by Dr. Schwartzman's colleague, Dr. Enrique Aradillas, M.D., who noted that Plaintiff had been treating with gabapentin (Neurontin) and had positive Tinel's, Wright's, and Roo's signs. (R. at 505.) Thereafter, Plaintiff followed up with Dr. Ardillas several times. (R. at 543, 606.) On December 12, 2013, Dr. Aradillas performed a stellate ganglion block at ¶ 6, which reduced Plaintiff's plain levels from 8/10 to 3/10. (R. 535-36.) The following February, Dr. Aradillas performed another stellate ganglion block at ¶ 6, which again reduced Plaintiff's pain levels from 8/10 to 3/10. (R. at 549-50.) On June 19, 2014, Dr. Aradillas administered a trigger point injection at the right shoulder/scapula, which reduced Plaintiff's pain level from 8/10 to 2/10. (R. at 612.) At a follow-up appointment on April 6, 2015, Dr. Aradillas noted that Plaintiff “does well” with ketamine treatments, and that the stellate and trigger point injection “seems to improve the response to ketamine.” (R. at 613.)

         On April 30, 2015, Dr. Aradillas completed an Attending Physician's Statement for Prudential, wherein he noted that Plaintiff had pain throughout the entire right side of her body and experienced “frequent pain flares” from her “severe CRPS, ” which “require rest.” (R. at 604-05.) Dr. Aradillas opined that Plaintiff could perform “no work.” (R. at 605.)

         C. State ...


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