Maldonado-Morales v. Kijakazi

• Decision Date: 23 February 2023
• Docket Number: CIVIL 1:22-CV-377
• Parties: SARA MALDONADO-MORALES, Plaintiff v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant
• Court: U.S. District Court — Middle District of Pennsylvania

SARA MALDONADO-MORALES, Plaintiff v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant

CIVIL No. 1:22-CV-377

United States District Court, M.D. Pennsylvania

February 23, 2023

MEMORANDUM OPINION

Martin C. Carlson United States Magistrate Judge

I. Introduction

Sara Maldonado-Morales applied for Social Security benefits on October 25, 2019, alleging that she had become totally disabled beginning on July 1, 2019. However, Maldonado actually was employed, both full and part-time, for some thirteen months after she claimed that she was totally disabled, from July 1, 2019 through August of 2020. Moreover five out of six medical experts who considered her case concluded that Maldonado could perform some work notwithstanding her impairments.

On these facts, the ALJ denied Maldonado's claim. Maldonado now appeals this decision, arguing that the ALJ erred in assessing her severe and non-severe impairments, and should have followed the sole medical opinion which supported her disability claim.

We evaluate this appeal against a highly deferential standard of review, one which calls upon us to affirm the decision of the ALJ if that decision is supported by “substantial evidence:”

[A] “term of art” used throughout administrative law to describe how courts are to review agency factfinding. T-Mobile South, LLC v. Roswell, 574 U.S.__,__, 135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).

Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019).

Mindful of the fact that substantial evidence, “means only-‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion,'” Biestek, 139 S.Ct. at 1154, we find that the ALJ adequately addressed the evidence in this case when concluding that Maldonado had not met the exacting standard for demonstrating an entitlement to disability benefits. Further, substantial evidence supported the ALJ's disability determination in this case, denying Maldonado's claim. Therefore, for the reasons set forth below, we will affirm the decision of the Commissioner denying this claim.

II. Statement of Facts and of the Case

On October 25, 2019, Sara Maldonado-Morales applied for disability and supplemental security income benefits under Titles II and XVI of the Social Security Act, alleging an onset of disability on July 1, 2019. (Tr. 15). Maldonado was born in 1979, was 40 years old at the time of the alleged onset of her disability, and was defined as a younger worker under the Commissioner's regulations. (Tr. 32). Maldonado had an eleventh grade education and prior employment as a sales clerk, waitress, and store laborer. (Id.) In this disability application, Maldonado alleged that she was disabled due to obesity, intraventricular meningioma, neurocognitive disorder, degenerative disc disease of the lumbar spine, arthritis of the left ankle joint, and migraine headaches. (Tr. 18).

Maldonado's disability application was highly unusual in at least one significant respect. Although Maldonado alleged that she had become totally disabled on July 1, 2019, it is entirely undisputed that she continued to work both full-time and part-time for another thirteen months past her alleged date of onset of disability, until August of 2020. (Tr. 17-18).

A. Maldonado's Clinical History and Activities of Daily Living

During the pertinent time period, Maldonado was seen, treated, examined, and assessed by a number of health care providers. Thus, a robust clinical record exists in this case. (Tr. 338-1103). Yet, while this treatment history is extensive, for the most part it is relatively unremarkable and contains scant evidence of wholly disabling impairments.

Maldonado initially reported symptoms of left hand weakness and tingling on July 14, 2019. (Tr. 367-429). Maldonado was hospitalized for three days. (Id.) During this time doctors performed a battery of tests, including a CT examination, which revealed a 3.3 by 1.8 by 2.8 cm intraventricular brain mass. (Tr. 356). This testing disclosed no evidence of acute hemorrhagic or ischemic infarct and by the time of her discharge on July 17, 2019, Maldonado was free from any neurological symptoms. (Tr. 369).

On August 7, 2019, Maldonado underwent an endoscopic procedure and colonoscopy to determine whether there was any metastatic disease present. (Tr. 356-62). These test results were also unremarkable, merely identifying some polyps, diverticulosis, and trivial hemorrhoids. (Tr. 362).

On September 24, 2019, Maldonado was seen by Dr. Denyse Allen complaining of headaches and reporting that she was stressed as she awaiting further diagnosis and treatment option for her intraventricular brain mass. (Tr. 455-56). Her physical examination results, however, were unremarkable as she displayed a normal range of motion, mood, affect, and behavior. (Tr. 456).

On October 9, 2019, Dr. Michael Glantz, a neurologist, examined Maldonado. (Tr. 435-37). During this clinical encounter, Maldonado acknowledged her continued employment, telling the doctor that she reduced her hours at Boscov's from 40 to 20-28 hours per week due to her headaches. (Tr. 436). The doctor's physical examination revealed normal strength and sensation on Maldonado's part; her heel-toe and tandem walking were adequate; her intellectual functioning tests demonstrated normal speech and language, and she was able to understand three-step commands and perform simple calculations. (Tr. 436). Dr. Glantz detected no evidence of a stroke and with respect to her intraventricular brain mass found that, “[t]here has perhaps been a very slight increase in the size of the lesion of the course of [Plaintiff's] three brain MRI scans (7/14/19, 8/8/19, 10/4/19); however, [she] appears at this point to be asymptomatic from her brain lesion and there is no hydrocephalus.” (Tr. 437). Dr. Glantz suggested that Maldonado's episodes of lefthand numbness might represent irritation of the median nerve in the carpal tunnel and recommended that she undergo another brain MRI in two to three months. (Tr. 437).

On October 15, 2019, Dr. Kristine Dziurzynski, M.D., a neurosurgeon, diagnosed Maldonado with an asymptomatic intraventricular meningioma, a non-malignant tumor. (Tr. 451). Maldonado's physical examination revealed no abnormalities and Dr. Dziurzynski simply recommended surveillance of the tumor at three and six months and then annually if stable. (Id.) Ten days later, on October 25, 2019, Maldonado was seen once again by Dr. Allen for bilateral wrist pain and numbness that she believed was carpal tunnel syndrome (Tr. 449). A physical examination at that time revealed a normal range of motion, as well as normal behavior, mood, and affect for Maldonado. (Tr. 449-50). Dr. Allen ordered an EMG/nerve conduction study and prescribed wrist splints for the plaintiff. (Tr. 450).

A November 19, 2019 CT examination revealed that Maldonado's meningioma was stable and unchanged in appearance. (Tr. 468). At that time Maldonado reported chronic migraine headaches but stated that “[s]he has been able to continue working” notwithstanding these symptoms. (Tr. 446).

In January of 2020, Maldonado was seen by Dr. Allen and Dr. Dziurzynski. During her appointment with Dr. Allen, Maldonado continued to display a normal mood, affect, and behavior, but complained of headaches. (Tr. 545-46). In the course of her appointment with Dr. Dziurzynski, the neurosurgeon, Maldonado indicated that she “has been able to continue working.” (Tr. 560). Her meningioma was found to be clinically and radiographically stable, and Maldonado was instructed to follow up in nine months, and thereafter annually. (Id.) Likewise, a function report completed by Maldonado in February of 2020 indicated that she retained the ability to work. In fact, Maldonado flatly stated: “ I am currently working at Boscov's as a cashier and stocker of luggage, toys candy and garden department.” (Tr. 303).

On March 5, 2020, Maldonado was seen in the emergency department of Good Samaritan Hospital after she was involved in a vehicular accident in which the electric bicycle she was riding was struck by a car. (Tr. 583-93). Her physical examination was unremarkable aside from an abrasion on her right elbow along with a sprain of her left wrist and ankle. (Tr. 586, 588). Moreover, a CT scan of her skull disclosed no significant change in her intraventricular brain mass. (Tr. 587). In a March 24, 2020 follow-up appointment with Dr. Allen, Maldonado reported that her symptoms had improved somewhat since the accident and disclosed that she had vacationed in Florida following this injury. (Tr. 707).

In May of 2020, Maldonado saw Dr. Thomas Sherman, who prescribed a course of physical therapy for her post-accident hip and ankle pain. (Tr. 685-86, 69091). An MRI of the left ankle revealed peroneal tenosynovitis and very mild arthritis of...