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Mazzanti v. Berryhill

United States District Court, E.D. Missouri, Eastern Division

August 1, 2018

NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration Defendant.



         Plaintiff Kirsten Mazzanti seeks review of the decision of Defendant Nancy Berryhill, Deputy Commissioner of Operations, Social Security Administration (SSA), denying his application for a period of disability and Disability Insurance Benefits under the Social Security Act.[1] (ECF No. 1).). Because the Court finds that substantial evidence supports the decision to deny benefits, the Court affirms the denial of Plaintiff's applications.

         I. Background and Procedural History

         On November 26, 2013, Plaintiff filed an application for a period of disability and Disability Insurance Benefits claiming that she was disabled as of January 1, 2010 due to: disc degeneration, obsessive compulsive disorder, neck issues/arthritis, fibromyalgia, migraines, anxiety, manic depression, irritable bowel syndrome, and post-traumatic stress disorder. (Tr. 182). The SSA denied Plaintiff's claims, and she filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 80, 87-88).

         The SSA granted Plaintiff's request for review, and the ALJ conducted a hearing in October 2014. (Tr. 100). In a decision dated February 24, 2015, the ALJ found that Plaintiff “ha[d] not been under a disability, as defined in the Social Security Act, from January 1, 2010, through the date of this decision.” (Tr. 23). Plaintiff subsequently filed a request for review of the ALJ's decision, which the SSA Appeal's Council denied. (Tr. 1, 6). Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as Defendant's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         I. The Administrative Proceeding

         A. Testimony at Hearing

         Plaintiff appeared with counsel at the administrative hearing in October 2014. (Tr. 33). Plaintiff was thirty-nine years of age and testified that she was 5'10”, weighed 225 pounds, and relied on her husband as her current source of income. (Tr. 35-37). Plaintiff stated she worked several years after her purported January 2010 onset date in retail and in home healthcare as a certified nursing assistant. Plaintiff could not remember when she last worked but explained that her back pain, fibromyalgia, migraines, and mental impairments eventually prevented her from working. (Tr. 38, 45).

         Plaintiff believed her back pain began in 2010, and she received treatment from her primary care physician (PCP), Dr. Patricia Hinkle, and chiropractor, Dr. Ryan Moeckel. Other than Neurontin, muscle relaxers, and a breast reduction to “alleviate some of the weight, ” Plaintiff received no other treatments. (Tr. 47). She alleged she was “narcotic sensitive, ” so she “took [herself] off all [her] narcotics.” (Tr. 48). Plaintiff recalled Dr. Moeckel restricted her to lifting no more than ten pounds or a gallon of milk and taking a break every thirty minutes. (Tr. 55-56). Additionally, Plaintiff stated that she was unable to carry laundry up and down the stairs or wash more than a few dishes at a time. (Tr. 56).

         Plaintiff testified that her mental impairments “became an issue” for her when she was nine years old and, from that point on, she was treated “off and on” her entire life. She stressed her anxiety prevented her going anywhere. (Tr. 58). She did not belong to any organizations or attend family events because she could not “deal” with “going out in public” or being around large groups of people. (Id.).

         In 2010, Plaintiff received counseling from a psychologist for “maybe a year and a half.” (Tr. 50). During that time, she also saw a psychiatrist who prescribed her medication. (Tr. 51). At the time of the hearing, her PCP, Dr. Hinkle, was providing Plaintiff's mental health treatment and prescribing a small dose of Klonopin. (Tr. 53). Plaintiff testified that Dr. Hinkle previously prescribed her Xanax and other antidepressants, but they caused adverse reactions because she was “very medication sensitive[.]” (Id.). Plaintiff had scheduled a post-trial appointment with Dr. Hinkle to “try for another medication.” (Tr. 54).

         B. Relevant Medical Records Before the ALJ

         The earliest evidence of Plaintiff's depression appears in a report from a May 2009 visit to a family doctor. Plaintiff's “constant and overwhelming” symptoms included “[an] anxious mood, decreased appetite, insomnia, crying spells, decreased ability to concentrate, fatigue, guilt, sadness, feelings of worthlessness, [f]rustration and tendency towards indecisiveness.” (Tr. 354). She admitted having suicidal thoughts but was not taking any antidepressants. (Id.). The doctor diagnosed her with depression and prescribed Zoloft.

         Plaintiff's first record of back pain was from a visit to her chiropractor, Dr. Moeckel, in January 2010. Dr. Moeckel diagnosed her with lumbar subluxation. (Tr. 496). In addition to seeing Dr. Moeckel, Plaintiff saw Dr. Hinkle several times later in the same year. Plaintiff did not mention back pain at an appointment in August but complained of back pain in September and October. (Tr. 376-79, 382, 384). Plaintiff stated she was seeing Dr. Moeckel and reported “some pain relief” as his treatment was “helping a little.” (Tr. 385). Dr. Hinkle ordered x-rays of Plaintiff's lower back, which showed a “[m]oderate decrease in diskal height at the L1-2, L2-3 and L3-4 disks.” (Tr. 392). In November, Dr. Hinkle prescribed Percocet because Plaintiff's “pain [worsened] with pretty much anything.” (Tr. 394).

         Treatment notes from a January 2011 visit to Dr. Hinkle's office revealed that Plaintiff was “positive for back pain” but “had been doing great [emotionally].” (Tr. 400). Plaintiff denied having suicidal thoughts. (Id.). She attributed this improvement to being able to work, which “[got] her out of the house.” (Id.). Dr. Hinkle did not prescribe additional medication for depression or refill Plaintiff's past prescriptions.

         Plaintiff did not return to Dr. Moeckel until February 2011, at which point he diagnosed her with lumbar and thoracic radiculitis, sacral/coccyx subluxation, and thoracic subluxation in addition to the lumbar subluxation. (Tr. 496). In April 2011, Dr. Hinkle noted Plaintiff experienced “some pain relief with rest and [P]ercocet.” (Tr. 394, 408). Later that year, Plaintiff returned to Dr. Hinkle with complaints of back pain and disclosed that she did “a lot of lifting at work.” (Tr. 411). Dr. Hinkle refilled Plaintiff's Percocet prescription in April 2011. (Tr. 428).

         Dr. Shajitha Nawaz, a psychiatrist, treated Plaintiff throughout 2011. In April, Dr. Nawaz performed a psychiatric evaluation. She noted Plaintiff was hospitalized twice as a teenager for psychiatric reasons. She also discussed Plaintiff's history of drug abuse. In May, June, and August reports, Dr. Nawaz noted Plaintiff exhibited borderline personality traits.

         In November 2011, Plaintiff presented to Dr. Hinkle with anxiety and “classic migraine.” (Tr. 429). Dr. Hinkle noted that Plaintiff's anxiety disorder “was originally diagnosed 1/2011” and her symptoms included constant “chest pain, dry mouth, light-headedness, palpitations, and shortness of breath.” (Tr. 429). She claimed “[m]arital discord, crowds or public places, and- everything” triggered her anxiety. (Id.). Plaintiff did “not feel like she has been getting any benefit from current counselor and psychiatrist.” (Tr. 432). Dr. Hinkle prescribed Xanax. (Id.).

         At a follow-up appointment in January 2012, Plaintiff reported she “[was] doing really, really well with [C]elexa.” (Tr. 438). Dr. Hinkle continued Plaintiff's prescription of Celexa and noted that Plaintiff also took Xanax “if she is going into a social situation that will usually cause a panic attack or occasionally to sleep.” (Id.).

         In April 2012, Plaintiff visited Dr. Hinkle because she “[had] been lifting and bending over a lot for the past couple of weeks, ” which caused back pain. Plaintiff was working full-time at a new job. Dr. Hinkle recommended heat and ice therapy along with rest. (Tr. 443). Dr. Hinkle noted no changes in Plaintiff's depression and anxiety medication or mood.

         Plaintiff returned to Dr. Hinkle's office in April, September, and November 2012. In December 2012, Plaintiff reported “she is still having pains, ” including “pains showing down her legs L>R. She feels like the L leg will go out on her at times.” (Tr. 449). In regard to her mental health, Plaintiff was “doing well.” (Id.).

         In February 2013, Plaintiff presented to Dr. Moeckel after she injured her lower spine lifting a 250-pound patient at work. (Tr. 497). Plaintiff described “severe constant sharp low back pain and remarkably severe constant shooting anterior pain in the left leg.” (Id.). Dr. Moeckel administered manipulation to T2, T3, L4, and RSI and electrical muscle stimulation to the lumbar region. (Tr. 498). Dr. Moeckel advised Plaintiff to use cold packs, visit him three times per week, and “not work, ” noting that she “has been placed on temporary total disability.” (Id.).

         Plaintiff saw an orthopedic surgeon in March 2013. He ordered x-rays and an MRI of her spine. The x-rays revealed Plaintiff suffered from “mild degenerative disc disease at ¶ 3 -L4, ” and the MRI showed “mild desiccation and disc space height loss seen at the L3-L4 level…remaining intervertebral discs are normal in appearance.” (Tr. 303, 305).

         Plaintiff returned to Dr. Moeckel in June 2013, complaining of pain in her right hip, buttock, and thigh. (Tr. 498). After Dr. Moeckel administered manipulation and electrical muscle stimulation, Plaintiff's “pain decreased.” (Tr. 499). Dr. Moeckel noted “patient [was] expected to reach maximum medical improvement.” (Id.). The same month, Plaintiff presented to the emergency room at Barnes Jewish ...

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