United States District Court, E.D. Tennessee, Greeneville Division
DENNIS H. INMAN, Magistrate Judge.
This matter is before the United States Magistrate Judge, by consent of the parties under 28 U.S.C. § 636, for final resolution. The plaintiff has filed a Motion for Judgment on the Pleadings [Doc. 18]. The defendant Commissioner has filed a Motion for Summary Judgment [Doc. 23]. Plaintiff's application for disability insurance benefits was denied administratively following a hearing before an Administrative Law Judge ["ALJ"].
The sole function of this Court in making this review is to determine whether the findings of the Commissioner are supported by substantial evidence in the record. McCormick v. Secretary of Health and Human Services, 861 F.2d 998, 1001 (6th Cir. 1988). "Substantial evidence" is defined as evidence that a reasonable mind might accept as adequate to support the challenged conclusion. Richardson v. Perales, 402 U.S. 389 (1971). It must be enough to justify, if the trial were to a jury, a refusal to direct a verdict when the conclusion sought to be drawn is one of fact for the jury. Consolo v. Federal Maritime Commission, 383 U.S. 607 (1966). The Court may not try the case de novo nor resolve conflicts in the evidence, nor decide questions of credibility. Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984). Even if the reviewing court were to resolve the factual issues differently, the Commissioner's decision must stand if supported by substantial evidence. Liestenbee v. Secretary of Health and Human Services, 846 F.2d 345, 349 (6th Cir. 1988). Yet, even if supported by substantial evidence, "a decision of the Commissioner will not be upheld where the SSA fails to follow its own regulations and where that error prejudices a claimant on the merits or deprives the claimant of a substantial right." Bowen v. Comm'r of Soc. Sec., 478 F.3d 742, 746 (6th Cir. 2007).
Plaintiff asserts that her disability onset date was December 31, 2000. Her insured status for disability insurance benefits expired on September 30, 2001. Her application for those benefits was filed over seven years later on November 13, 2008. In order to be eligible for disability insurance benefits, the plaintiff must demonstrate that she was disabled on or before September 30, 2001.
Plaintiff was 33 years of age at the time her insured status expired, a "younger" individual. She has at least a high school education. There is no dispute that she cannot return to her past relevant work as a real estate agent.
The medical record is fairly extensive, although the vast majority of the records are from the period after her insured status expired. The medical history is summarized in the defendant's brief as follows:
The relevant medical evidence prior to Plaintiff's DLI reflects that Plaintiff had a magnetic resonance imaging (MRI) of her brain on December 30, 1999, which demonstrated multifocal bilateral cerebral white matter lesions and was suggestive of demyelinating disease (Tr. 248). An April 10, 2001 MRI also showed lesions, which was noted that, given her history, mostly likely represented demyelinating process (Tr. 246). Progress notes from the Hammond Clinic, dated February 7, 2001, indicated that Plaintiff would start Copaxone to treat her multiple sclerosis (MS), which was noted to be stable (Tr. 260). Progress notes, dated February 13, 2001, also showed that she had complaints of migraines and was started on Verapamil (Tr. 259). Notes from the Hammond Clinic dated January 2001 through April 2001 showed that Plaintiff was prescribed Prozac and Depokote (Tr. 255-58).
On April 25, 2001, Plaintiff reported that she had fallen a week earlier and reported that she had drop foot of the right leg due to MS (Tr. 255). Her right knee was swollen with pain (Tr. 255). Diagnostic impression was cellulitis (Tr. 255). On April 27, 2001, the swelling and erythema in Plaintiff's right knee were markedly reduced (Tr. 254). Her pain was reduced also, although she had some pain in her leg (Tr. 254). On May 2, 2001, it was noted the swelling and soreness were reduced (Tr. 254). On May 9, 2001, Plaintiff had tenderness in her right knee with soreness on flexion but no effusion (Tr. 253). The rest of her examination was normal (Tr. 253). Plaintiff had no right knee pain on May 23, 2001, and her knee exam was within normal limits other than localized thickening of her skin (Tr. 253).
Progress notes from her treatment on May 28, 2001, showed that Plaintiff complained of hand tremors, episodic numbness of the right leg, poor focus, increased headaches, fatigue, and falling (Tr. 252). The examination found some visual symptoms and clonusin the right lower extremity, but motor function was 5/5 in the bilateral upper extremities and 5/5 in the bilateral lower extremities (Tr. 252). Dorsal flexion was 4/5 on the right and 5/5 on the left, and plantar flexion was 5/5 on the right and 5/5 on the left (Tr. 252). The assessment was MS, fatigue, and depression (Tr. 252). Plaintiff appears to have next presented four months later on September 28, 2001, for a four-month checkup (Tr. 251). Her diagnoses of MS and depression were noted, although much of the treatment note is illegible (See Tr. 251). These were the last records from prior to Plaintiff's DLI of September 30, 2001.
Plaintiff continued to treat at the Hammond Clinic on October 31, 2001, with complaints of vertigo, light-headedness, and tingling of her left arm for two weeks (Tr. 250). Plaintiff's medications were reviewed; however, she did not see a doctor (Tr. 250). Plaintiff returned on November 6, 2011, reporting dizziness for one and a half weeks, some difficulty walking, and a tingling sensation intermittent in her left upper extremity (Tr. 250). Plaintiff had not been using Copaxone noting it was "too much hassle" (Tr. 250). Plaintiff was alert with a blunted affect, and she reported that she had contacted a new psychiatrist (Tr. 250). It was noted that Plaintiff had a recent exacerbation of her MS (Tr. 250). Plaintiff appears to have missed an appointment on February 13, 2002, and she had a prescription for Detrol refilled on February 25, 2002 (Tr. 249).
Records reflect that Plaintiff treated with Allergy, Asthma and Clinical Immunology Associates, but these cover the period of September 2002 to September 2003, after Plaintiff's DLI (See Tr. 268-95). These records reflect that Plaintiff continued to complain of frequent headaches on December 31, 2002 (Tr. 277).
Plaintiff began treatment with Mark A. Muckway, M.D., at Comprehensive Neurologic Services on July 9, 2002, about 10 months after her DLI (Tr. 320-22). Dr. Muckway recited that Plaintiff had a positive review of her neurological symptoms, noting intermittent difficulty finding words, concentration, and intermittent vertiginous difficulty with "disbalance" but she had not fallen (Tr. 320). Dr. Muckway noted that Plaintiff had been put on Copaxone, but "[d]ue to the information as well as some psychosocial issues of changing locations, occupations, and marital situations" she went off that treatment (Tr. 320). Neurologic exam showed that Plaintiff was alert and oriented times three with normal speech and with intact cognition (Tr. 321). Dr. Muckway noted Plaintiff had occasional word finding difficulties "but not objectively" (Tr. 321). Plaintiff had increased tone with "several beat" clonus in the lower extremities which was not sustained (Tr. 321). Her reflexes were 2 in her upper extremities and 3 in the lower extremities with Babinski signs (Tr. 321). Plaintiff had a slightly spastic wide-based gait, she could not heel walk adequately, and her tandem was fair to poor (Tr. 321). Dr. Muckway noted that Plaintiff had a history of relapsing/remitting MS, and they were going to continue Plaintiff's regimen and add Provigil (Tr. 321).
On August 2, 2002, Plaintiff reported no symptoms or suggestion of MS flair (Tr. 319). On examination Plaintiff's motor examination revealed normal tone and bulk with minimal "disbalance" problems (Tr. 319). Her cranial nerves were intact, and she had slight lower extremity reflex preponderance and equivocal toe signs (Tr. 319). Plaintiff was to re-start Copaxone and was to take Neurontin for her headaches (Tr. 319). On September 5, 2002, Plaintiff had no flare or suggestion of exacerbations, motor examination revealed normal tone and bulk, and her reflexes were nonpathologic (Tr. 318). Plaintiff admitted to forgetting to take the Copaxone at times as well as her second dose of Provigil (for promotion of wakefulness) (Tr. 318). Plaintiff was to continue Copaxone for her MS and Provigil for fatigue and her Neurontin was increased for treatment of her headaches (Tr. 318).
Records from Hendricks Community Hospital contain results of diagnostic testing reflecting no active disease of her chest ...