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Gaathje v. Colvin

United States District Court, D. Connecticut

February 17, 2017



          Vanessa L. Bryant, U.S.D.J.

         This is an administrative appeal following the denial of the Plaintiff, Nicole Gaathje's, application for disability insurance benefits (“DIB”) and supplemental security income benefits (SSI)[1] It is brought pursuant to 42 U.S.C. §§ 405(g).

         Nicole Gaathje (“Plaintiff” or “Gaathje”) has moved for an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”), or remanding the case for rehearing. [Dkt. No. 13.] The Commissioner, in turn, has moved for an order affirming the decision. [Dkt. No. 17.] Magistrate Judge Sarah A. L. Merriam rendered a Recommended Ruling on the Cross Motions, recommending Plaintiff's Motion to Reverse the Decision of The Commissioner be denied, and recommending Defendant's Motion to Affirm be granted. [Dkt. No. 19.] Plaintiff filed an Objection to the Recommended Ruling [Dkt. No. 20], and Commissioner filed a Response in favor of the Recommended Ruling. [Dkt. No. 21.] The Court accordingly reviews de novo the Magistrate Judge's Recommended Ruling. 28 U.S.C. § 636(b)(1)(B); Fed.R.Civ.P. 72(b)(3). The Court may adopt, reject, or modify, in whole or in part, the Magistrate Judge's Recommended Ruling. 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b).

         For the following reasons, the Recommended Ruling is adopted, Gaathje's Motion for an Order Reversing or Remanding the Commissioner's Decision [Dkt. No. 13] is DENIED, and the Commissioner's Motion to Affirm that Decision [Dkt. No. 13] is GRANTED.

         I. Factual Background

         The following facts are taken from the parties' Joint Stipulation of Facts (“Joint Stipulation”) [Dkt. No. 16] unless otherwise indicated, and are undisputed unless otherwise indicated.

         a. Plaintiff's Background

         Gaathje was born on October 21, 1975. [Dkt. No. 16 at 1.] She did not graduate from high school and has not obtained a GED. Id. She was last insured on June 30, 1996.[2] [Id. at 211.] Gaathje's alleged disability began on or about April 2, 2011. Id. at 1. On December 21, 2011 Gaathje filed an application for disability benefits, and on December 23, 2011, she applied for supplemental security income. [Dkt. No. 11-6 at 183, 191.] On February 24, 2012, a disability adjudicator in the Social Security Administration denied her initial request for disability benefits and thereafter denied her request for reconsideration. [Dkt. Nos. 11-4 at 60, 72.]

         On August 29, 2013, Gaathje appeared (with counsel) for a hearing before an ALJ. [Dkt. No. 11-3 at 31.] On October 23, 2013, the ALJ issued a decision denying benefits. Id. at 17. On May 18, 2015, the appeals council denied Gaathje's request for review of that decision thereby making the ALJ's decision the final decision of the Commissioner. Id. at 1. This appeal followed.

         b. Plaintiff's Medical History

         Gaathje was first examined for blurred vision, shortness of breath, and chronic dizziness on August 7, 2009. Id. at 1. On October 20, 2009, Dr. N.J. Holzer noted Gaathje showed symptoms of vertigo with hearing loss, and that her August 9 MRI showed no other conditions except indications of sinus disease. Id. at 1.

         In the years following her October 2009 diagnosis of vertigo and hearing loss, Gaathje has reported various symptoms to physicians, including anxiety, trouble sleeping, tinnitus, pain in her back, hands, wrists, elbows, knees, legs, ankles and feet, heartburn, and difficulty breathing when exposed to irritants in the air. [Id. at 2-4; Dkt. No. 11-8 (Medical Records) at 353 (anxiety, back pain, abdominal pain as of August 2011), 381 (tinnitus and continued dizziness, hearing loss, vertigo, and joint pain as of March 2012), 369-70 (continued anxiety, dizziness, back and joint pain, and gastroesophageal reflux as of April 2012), 411 (continued back pain, abdominal pain, anxiety in May 2012), 494 (hand pain, difficulty breathing as of October 2012), 447 (joint pain as of April 2013), 443 (anxiety and trouble sleeping as of April 2013).]

         A physical exam in March of 2012 by Jessica Plasse, APRN and accompanying consultation by Dr. Gregory Lesnik found that Gaathje had symptoms consistent with vertigo and “possible Meniere's disease given her history of hearing loss in the left ear.” [Dkt. No. 11-8 at 382.] Dr. Lesnik ordered a diagnostic test to determine whether Gaathje experienced Meniere's disease or vestibular migraines. Id. at 382. The diagnostic test, a videonystagmography (VNG) evaluation, found Gaathje had “borderline normal VNG” with “not clinically significant” variations. Id. at 416. In conjunction with the VNG, Gaathje completed a questionnaire regarding her dizziness and hearing loss, and also reported she experienced impaired vision, lip numbness and tingling, weakness in her arms or legs, and a “tendency to get upset easily.” Id. at 411-12. At a follow-up appointment in June 2012, Dr. Lesnik reviewed the diagnostic results and concluded “Meniere's disease is a very likely diagnosis.” Id. at 426. Similarly, in conjunction with an April 2012 physical exam also by Ms. Plasse, Dr. Robert Sidman also concluded Gaathje experienced “dizziness/possible Meniere's disease.” [Dkt. No. 11-8 at 391.]

         In addition to Meniere's disease, physical exams by Ms. Plasse as early as August 2011 consistently assess that Gaathje experiences anxiety disorder. [Dkt. No. 11-8 at 354.] Gaathje has taken various anxiety medications since 2011. [See e.g., id. at 354 (August 2011 anxiety medication), 391 (April 2012 anxiety medication.] When Gaathje switched primary care doctors in March 2013, Andrea Dameron, APRN, referred Gaathje for a mental health evaluation. Id. at 440. At the evaluation in April 2013, Gaathje reported anxiety that began with trauma during her adolescence and has increased in recent years due to medical complications. Id. at 444. Gaathje reported that her “medical issues . . . keep her from doing things she wants to do.” Id. at 444. Despite that, Gaathje listed her personal strengths as artistic talent, gardening, her sense of humor, and her relationship with her children. Id. at 443. Beth LaFontaine, LADC, Gaathje's mental health evaluator, found no abnormalities in Gaathje's mental status or behavior. Id. at 444. Ms. LaFontaine concluded Gaathje experienced anxiety, educational problems, impairment in social, occupational, or school functioning, and other psychosis and environmental problems, and created a treatment plan requiring Gaathje to attend weekly therapy sessions. Id. at 444-46.

         In May 2013, Lisa Harrison, APRN also evaluated Gaathje's mental health. Id. at 456. Ms. Harrison found Gaathje had normal thought processes, mood and affect, associations, judgment and insight. Id. at 458. Ms. Harrison found no hallucinations, delusions, or psychotic thoughts. Id. Ms. Harrison prescribed two anxiety medications with a plan to assess side effects and efficacy at a follow-up appointment. Id. at 456-58. At a subsequent appointment two weeks later, Gaathje reported continued anxiety and trouble sleeping. Id. at 466. Ms. Harrison adjusted Gaathje's medication. Id. at 466.

         Gaathje has also been treated for abdominal pain and irritable bowels. In January of 2011, Gaathje reported to Ms. Plasse abdominal pain and irritable bowels, but stated symptoms were controlled with prescribed medication along with over-the-counter heartburn medication. Id. at 341. In April 2012, Ms. Plasse examined Gaathje and Dr. Sidman prescribed Gaathje medication to treat gastroesophageal reflux and abdominal bloating, as well as continued medication for Gaathje's anxiety and dizziness. Id. at 391. In addition, Gaathje's medical records indicate a history of gestational diabetes. Id. at 447.

         Ms. Plasse has also treated Gaathje for Reactive Airways Dysfunction Syndrome. [Dkt. No. 11-9 (Continued Medical Records) at 494.] Gaathje reported “deep breathing” and a cough, for which Ms. Plasse prescribed use of two inhalers. Id. at 494.

         Gaathje also reported hand pain in October 2012. Id. at 494. An x-ray of the hand in October 2012 was normal. Id. at 527. In June 2013, Gaathje reported to the emergency room with wrist, hand, elbow, and foot pain. Id. at 538. X-rays and evaluation showed possible rheumatoid arthritis, but the treating emergency physician could not exclude other possible diagnoses. Id. The emergency physician treated Gaathje with pain medication. Id. In August 2013, Gaathje saw Dr. Sandeep Varma regarding her joint and extremity pain. Id. at 519. Dr. Varma found no evidence of inflammatory disease, but likely polyarthralgia. Id. Dr. Varma prescribed Celebrex for Gaathje's pain. Id.

         c. Expert Examinations and Opinions

         On August 29, 2013, APRN Dameron, who treated Gaathje for the ten (10) week period beginning May 29, 2013 and ending August 8, 2013, completed a medical source statement regarding Gaathje. [Dkt. No. 11-9 at 558.] Ms. Dameron's statement indicated that that Gaathje has the following limitations: 1) she may occasionally and frequently lift 10 pounds; 2) she may stand, walk, and sit for six hours in an eight hour day; 3) she is limited in pushing and pulling; 4) she cannot kneel or crawl; 5) she can occasionally climb, balance, crouch, and stoop; 6) she is limited in the ability to finger and can reach only occasionally; 7) she is limited in hearing; and 8) she is limited in her exposure to noise. Id. at 558-61. Ms. Dameron lists as the reasons for Gaathje's limitations polyarthralgia involving multiple joints, vertigo, hearing loss, Meniere's Disease, and chronic tympanic disturbances. Id. at 558-61.

         Prior to Dr. Damerons assessment, on February 23, 2012, Dr. Barbara Coughlin, a State agency medical consultant, reviewed Gaathje's medical records, communicated with Gaathje, and provided an analysis for Gaathje's disability benefits claim. [Dkt. No. 11-4 at 54.] Dr. Coughlin found Gaathje's vestibular system disorder (vertigo and dizziness) constituted a severe medically determinable impairment. Id. at 56-7. Dr. Coughlin found Gaathje's statements regarding her symptoms “partially credible, ” in light of medical assessments showing “mild” or “intermittent” causes for her reported symptoms. Id. at 57. Dr. Coughlin found Gaathje had no exertional limitations, could climb ramps or stairs occasionally, could never climb ladders, could occasionally balance, and could stoop, kneel, crouch, or crawl without limitation. Id. at 57. Dr. Coughlin also found Gaathje should avoid all exposure to “hazards (machinery, heights, etc.).” Id. at 58. All limitations were ascribed to Gaathje's vertigo and dizziness. Id. at 57-58.

         Finally, on July 11, 2012, Dr. Nabil Habib, a State agency medical consultant, reviewed Gaathje's medical records and information supplied by Gaathje, and provided a second analysis for Gaathje's disability benefits claim. [Dkt. No. 11-4 at 68.] Dr. Habib also found Gaathje's vestibular system disorder constituted a severe medically determinable impairment. Id. at 68. Like Dr. Coughlin, Dr. Habib found Gaathje's account of her symptoms partially credible based on mild or intermittent evidence of causal conditions. Id. at 69. Dr. Habib determined Gaathje had the same limitations Dr. Coughlin identified, caused by Gaathje's vertigo and dizziness. Id. at 69-71.

         d. The Hearing Before the ALJ

         On August 29, 2013, Gaathje appeared for a hearing before ALJ Ryan Alger. [Dkt. No. 11-3 at 31.] Gaathje was represented by counsel. Id. at 33. Gaathje testified she last worked in 2011, as a plant merchandiser in customer service for Lowe's Home Store. Id. at 36. Gaathje stated she ceased working after “only a couple months” because the work was too physically taxing. Id. at 36. Gaathje explained “it was a lot of lifting and bending, and walking, standing.” Id. at 36-37.

         Gaathje testified to her abilities and disabilities at the hearing. She testified that she currently lives with her husband and three children, aged eighteen, sixteen, and eight (as of the time of the hearing). Id. at 37. Gaathje indicated bright lights trigger her vertigo and dizziness, and that she has to wear sunglasses in the grocery store. Id. at 38. In 2011, she had a vertigo episode triggered by viewing headlights and street lamps while driving at night. Id. at 37. As a result, she no longer drives. Id. In fact, Gaathje indicated the fluorescent lights at the hearing made her dizzy, and it appears from the transcript the ALJ turned off the overhead lighting for her. Id. at 37-38.

         Gaathje testified she usually feels comfortable lifting and carrying up to five pounds at a time, but that sometimes lifting a gallon of milk “aggravate[s]” her symptoms. Id. at 42. Her joint pain prevents her from cooking 2-3 times per week, and certain cooking tasks, like “lift[ing] the pan [of pasta] up to strain the water, ” are particularly painful. Id. at 39, 41. She also has difficulty doing laundry. Id. at 39. However, Gaathje can regularly load her dishwasher and dust, and her children and husband help her with other chores as necessary. Id. at 39.

         In addition, Gaathje indicated she sometimes has trouble getting into and out of bed because it requires her to bend her knees. Id. at 40. Gaathje testified she has trouble with activities requiring her to lift her arms above her head, including putting on a shirt and washing her hair, but she can otherwise dress and bathe herself. Id. Gaathje agreed with the ALJ's characterization that “some days are better than others.” Id. at 39.

         Gaathje has vertigo episodes about twice a week, they occur at random, and they last roughly half an hour. Id. at 42-43. When she has a vertigo episode, the room spins and she is left with “no energy.” Id. at 43. Medication helps to manage her episodes, however, she testified it's “usually a good two days before I start to feel normal again.” Id. Gaathje also indicated she gets migraines two or three times per week, sometimes concurrent with vertigo episodes. Id. She manages migraines by lying down with a cold compress and taking medicine. Id. at 44. A migraine typically lasts three to four hours. Id. Migraines and vertigo episodes are also sometimes accompanied by blurry vision. Id. In addition, Gaathje indicated her ears ring two to three times per month, for about half an hour per episode. Id. at 45.

         Gaathje indicated she sometimes experiences panic attacks when away from home, caused by fear that she might have a vertigo episode. Id. at 46. Panic attacks cause her shortness of breath and racing thoughts. Id. Gaathje participates in counseling sessions twice per week for anxiety treatment, and also sees a psychiatrist monthly. Id. at 45. The psychiatrist has prescribed her with ...

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