United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp, II United States Magistrate Judge.
June Gipson (“Plaintiff”) filed a complaint
against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny disability insurance
benefits (“DIB”). (Doc. 1). The district court
has jurisdiction under 42 U.S.C. § 405(g). The parties
consent to the exercise of jurisdiction by the undersigned in
accordance with 28 U.S.C. § 636(c) and Civil Rule 73.
(Doc. 13). For the reasons stated below, the Court affirms
the Commissioner's decision denying benefits.
filed for DIB on August 6, 2013, alleging a disability onset
date of July 16, 2007. (Tr. 173). Plaintiff's date last
insured for DIB was December 31, 2011. (Tr. 192).
Plaintiff's DIB claim was denied initially (Tr. 113) and
upon reconsideration (Tr. 125). On January 2, 2014, Plaintiff
filed a Request for Hearing. (Tr. 130-31). Thereafter, on May
12, 2015, Plaintiff (represented by counsel) appeared before
an Administrative Law Judge (“ALJ”). (Tr. 36-87).
The ALJ denied Plaintiff's application for DIB, finding
that from the alleged onset date to the date last insured,
Plaintiff was capable of performing a reduced range of light
work. (Tr. 23). The Appeals Council denied Plaintiff's
request for a review of the ALJ's decision, making it the
final decision of the Commissioner. (Tr. 1). On May 10, 2016,
Plaintiff filed the instant action for judicial review
pursuant to 42 U.S.C. § 405(g). (Doc. 1).
was born on August 6, 1957, and was fifty-seven years old at
the time of the administrative hearing. (Tr. 88). Plaintiff
was married, had two adult children, a high school degree,
and a driver's license. (Tr. 41, 43, 56). For eighteen
years, Plaintiff worked for Coltene-Whaledent, employed as a
machine and hand packager, general inspector, compounder, and
store laborer. (Tr. 45-49, 72-73).
Records Prior to Date Last Insured
Atul Goswami had been Plaintiff's treating physician
since 2001. (Tr. 277). Dr. Goswami noted that, in May 2006,
Plaintiff reported pain in both upper extremities, as well as
numbness and tingling in both upper extremities, her hands,
and fingers. Id. In December 2006, Dr. Goswami
ordered an MRI of Plaintiff's cervical spine that
revealed mild relative congenital central canal stenosis
throughout the cervical spine due to congenitally short
pedicles. (Tr. 285). In addition, the MRI revealed mild
multilevel cervical degenerative disc disease with multilevel
central canal stenosis that was moderate at the C5-C6 and
C6-C7 levels. Id. There was focal endplate
osteophyte formation versus a small broad based left
paracentral disc protrusion at the C6-C7 level. Id.
Furthermore, Dr. Goswami noted a probable small disc
protrusion at ¶ 7-T1, causing only mild central canal
stenosis but no cord deformity, and a possible, but very mild
neural foraminal narrowing at the C6-C7 level. Id.
Thereafter, Plaintiff saw Dr. Georges Markarian, a
neurosurgeon, who diagnosed Plaintiff with herniated discs at
¶ 5-C6 and C6-C7. (Tr. 286). As a result, Dr. Markarian
performed partial C5, C6, and C7 corpectomies, arthrodesis at
¶ 5-C6 and C6-C7, inserted biomedically threaded bone
dowels at ¶ 5-C6 and C6-C7, and plating from C5 through
began physical therapy on April 26, 2007. (Tr. 324). The
treatment goals were to: 1) return Plaintiff to a 10/10
activity level and to be able to hold her grandchild; 2)
return her range of motion to normal; and 3) be able to walk
for exercise. Id. Plaintiff completed physical
therapy on July 3, 2007, attaining her treatment goals. (Tr.
2007, Dr. Goswami completed a form regarding Plaintiff's
symptoms and treatment after her neck surgery. (Tr. 277-78).
He noted that Plaintiff had a “good response” to
surgery, but she still had some pain. (Tr. 278). Dr. Goswami
said Plaintiff could sit okay, and stand and walk better.
Id. However, he said she was unable to bend, stoop,
lift, or grasp. Id.
12, 2007, Plaintiff returned to Dr. Markarian for
post-surgical evaluation. (Tr. 281). She said she was doing
very well, and Dr. Markarian noted no obvious neurological
deficits. Id. Thereafter, on July 20, 2007, Dr.
Markarian reexamined Plaintiff who again stated she was doing
well and had no specific complaints. (Tr. 280). Dr. Markarian
noted Plaintiff's back looked good and the bone graft was
starting to fuse. Id. He also remarked that there
was a gap that would have to be closely followed.
Id. However, Dr. Markarian did not identify any
complications. (Tr. 282).
went to the emergency room on February 17, 2011, for a
urinary tract infection. (Tr. 301). She did not have any pain
on palpitation in the cervical, thoracic, or lumbar spine.
(Tr. 303). The hospital discharged Plaintiff approximately 12
hours later. Id.
received mental health care at the Center for Akron
Psychiatry in 2006 and 2007 with Dr. Todd Ivan. (Tr. 259-74).
Dr. Ivan diagnosed Plaintiff with major depression and panic
disorder and prescribed Pamelor and Xanax. (Tr. 273-74).
However, by June 2007, Dr. Ivan said Plaintiff's
condition had improved, indicating: no depression; only mild
anxiety; cooperative demeanor; good eye contact; normal
activity; logical and goal-directed thought processes and
content; good judgment and insight; intact memory; good
attention and concentration; and full and appropriate affect.
evening of October 14, 2009, Plaintiff went to the emergency
room with reports of hallucinations starting the day before.
(Tr. 314). Plaintiff's husband had left her five days
prior to the start of her hallucinations. Id. The
examining physician observed Plaintiff was alert, oriented,
pleasant, conversational, with normal speech, range of
motion, and affect. (Tr. 315). The diagnostic impression was
acute psychosis versus acute stress reaction versus
depression. Id. The hospital discharged Plaintiff
four hours later on October 15, 2009. Id.
Records After Date Last Insured
visited Dr. Goswami on March 14, 2013, complaining of a
painful cough with greenish mucus. (Tr. 373). She did not
complain of any back or neck pain. Id.
went to the emergency room on April 12, 2013, complaining of
back and left shoulder pain starting a couple of days prior.
(Tr. 293). Plaintiff reported some numbness and difficulty
moving her left arm. Id. Plaintiff received pain
medication and instructions to follow up with her primary
care physician and neurosurgeon. (Tr. 294).
April 22, 2013, Dr. Goswami diagnosed Plaintiff with cervical
and lumbar radiculopathy; however, he noted her
musculoskeletal, neurologic, and psychiatric examinations
were normal. (Tr. 369-72). On April 25, 2013, Dr. Goswami
ordered an MRI of Plaintiff's cervical spine that
revealed postsurgical changes of the C5-C6 and C6-C7 levels
as well as C4-C5 mild canal stenosis with mild diffuse disk
bulging. (Tr. 289). Dr. Goswami also ordered an MRI of her
lumbar spine that showed only minimal disk bulging at the
L1-L2 level without central canal stenosis. (Tr. 290).
referral from Dr. Goswami, Plaintiff saw Shelly Krampf, a
physical therapist, on May 15, 2013, to reduce her neck and
lower back pain. (Tr. 375). Plaintiff reported her neck pain
had increased five weeks prior, and her lower back pain had
increased over the past year. Id. Plaintiff had a
reduced range of motion in her trunk and cervical spine.
Id. Ms. Krampf noted Plaintiff was able to walk with
no acute distress; however, she had a lateral shift to the
right. Id. Ms. Krampf observed Plaintiff's
“upper extremity range of motion [was] within normal
limits.” Id. She also observed Plaintiff's
“foot and ankle motions are within normal
limits.” Id. Plaintiff's “side
bending and rotation right and left [were] within functional
limits” and her “lower extremity range of motion
[was] within functional limits.” Id.
Goswami supplied a medical source opinion on September 21,
2013. (Tr. 384). He opined Plaintiff could occasionally carry
five pounds and frequently carry two pounds; could stand and
walk for 30 minutes at a time, for a total of two hours; and
could sit for ten hours without interruption and for three
hours total during an eight-hour workday. (Tr. 383). He
also opined that Plaintiff could rarely climb, balance,
stoop, crouch, kneel, crawl, reach, push, pull, or use fine
or gross manipulation. Id. Dr. Goswami opined that
Plaintiff's pain would interfere with her concentration,
cause her to be off task, and cause absenteeism. (Tr. 384).
Lastly, he opined that Plaintiff would need six unscheduled
breaks during the workday. Id.
October 1, 2013, Dr. Goswami indicated Plaintiff continued to
have pain in the lumbar and cervical regions, but the pain
did not cause any motor loss. (Tr. 368). Dr. Goswami observed
Plaintiff's range of motion was limited in the lumbar
region. Id. In contrast to his September 21, 2013
opinion, he opined that Plaintiff could perform fine and
gross manipulation. Id. He also noted
Plaintiff's gait was slow, but an ambulatory aid was not
medically necessary. Id.
February 2014 emergency room visit, Plaintiff reported
increased neck pain after lifting a heavy bag of dog food.
(Tr. 398, 423). She returned to physical therapy on March 26,
2014, reporting increased neck pain over the last month or
two. (Tr. 397). At that visit, Plaintiff also stated her
lower back pain had been occurring for the last “2
years this time.” (Tr. 414). On July 30, 2014,
Plaintiff's physical therapist discharged her from
physical therapy with no improvement in her neck or back
pain. (Tr. 493).
August 8, 2014, Plaintiff saw an orthopedist who observed a
limited range of motion in her neck and recommended Plaintiff
continue physical therapy and see Dr. Markarian. (Tr.
423-24). On November 26, 2014, Plaintiff received a lumbar
epidural injection, which lowered her pain. (Tr. 465). X-Rays
of Plaintiff's spine, taken on December 29, 2014, showed
no fractures or subluxations, well-preserved disc spaces,
minimal anterior osteophyte formation at ¶ 3 and L4, and
only minimal degenerative changes at the L4-5 and L5-S1 facet
joints. (Tr. 464).
April 16, 2015, Dr. Goswami opined Plaintiff could lift five
pounds frequently, was limited to standing for ten minutes at
a time and for a total of one hour during the workday, and
limited to sitting for 30 minutes at a time and two hours
total during the workday. (Tr. 543). Furthermore, he opined
that Plaintiff could rarely climb, balance, stoop, crouch,
kneel, crawl, reach, or push. (Tr. 543-44). However, he was
of the opinion that Plaintiff could occasionally perform fine
manipulation. (Tr. 544). He characterized Plaintiff's
pain as moderate, and submitted her pain would interfere with
her concentration, take her off task, and cause absenteeism.
Id. Dr. Goswami opined that Plaintiff's
limitations were caused by cervical and lumbar spinal
stenosis. (Tr. 543-44).
21, 2013, Dr. Ivan reported Plaintiff had a cooperative
demeanor, normal activity, and good eye contact. (Tr. 361).
She had a normal speech rate, was coherent, and spontaneous.
Id. She exhibited good judgment, insight,
concentration, full and appropriate affect, intact memory,
and no anxiety or hallucinations. Id. However, Dr.
Ivan noted Plaintiff still ...