Sincavage v. Saul, Civil No. 1:19-CV-888

CourtUnited States District Courts. 3th Circuit. United States District Court of Middle District of Pennsylvania
Writing for the CourtMagistrate Judge Carlson
PartiesANGEL SINCAVAGE, Plaintiff v. ANDREW SAUL, Commissioner of Social Security, Defendant
Docket NumberCivil No. 1:19-CV-888
Decision Date29 May 2020

ANDREW SAUL, Commissioner of Social Security,1 Defendant

Civil No. 1:19-CV-888


May 29, 2020

(Magistrate Judge Carlson)


I. Introduction

The Supreme Court has recently underscored for us the limited scope of our review when considering Social Security appeals, noting that:

The phrase "substantial evidence" is 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."

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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).

In the instant case, Angel Sincavage applied for disability insurance benefits under Title II of the Social Security Act on January 11, 2016, alleging disability due to vertebrobasilar insufficiency and post-traumatic stress disorder from a car accident. (Tr. 159). However, after a consideration of the medical records and opinion evidence, which generally showed that Sincavage's physical impairments were treated with sporadic visits to specialists and minimal pain medications, and that her mental health issues were being treated with conservative outpatient therapy, the Administrative Law Judge ("ALJ") who reviewed this case concluded that Sincavage could perform a range of light work with limitations and denied her disability application.

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 substantial evidence supported the ALJ's findings in this case. Therefore, for the reasons set forth below, we will affirm the decision of the Commissioner denying this claim.

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II. Statement of Facts and of the Case

On January 11, 2016, Angel Sincavage applied for disability and supplemental security insurance benefits, alleging an onset date of disability beginning September 25, 2015 due to vertebrobasilar insufficiency and post-traumatic stress disorder from a car accident. (Tr. 159). Sincavage was approximately 51 years old at the time of the alleged onset of her disability and had prior employment as a high school guidance counselor. (Tr. 32). She had a college education, including a Master's degree, and could communicate in English. (Id.).

With respect to Sincavage's physical impairments, the record indicates that Sincavage's physical impairments began or were exacerbated by a motor vehicle accident in 2012. She had x-rays of the thoracic and cervical spine in September 2015, which showed multilevel mild degenerative changes in the thoracic spine and muscle spasm with degenerative changes in the cervical spine (Tr. 23-24). In October 2015, an MRI of the cervical spine showed mild spondylosis and mild canal stenosis. (Tr. 24). Sincavage was also seen for wrist pain in November 2015, and it was noted that she took pain medication for her wrist and wore a brace. (Id.)

Sincavage was seen by her primary care provider, Dr. Prahalad, throughout the alleged period of disability. (Tr. 453-62). It was noted in February of 2016 that Sincavage had difficulty walking and dizziness due to her VBI diagnosis. (Tr. 454). It was also noted that she was severely depressed and confused. (Id.) At a visit in

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May 2016, it was noted that Sincavage was experience fatigue, foot pain, neck pain, and memory loss. (Tr. 456). On June 29, 2016, Dr. Prahalad's notes state that Sincavage had fallen down the stairs and was using crutches or a cane to help her walk. (Tr. 456-57). Dr. Prahalad reported that Sincavage was very depressed but denied any suicidal ideation. (Tr. 457). In August and September of 2016, Dr. Prahalad again noted Sincavage's depression and forgetfulness, as well as her foot and neck pain. (Tr. 458). In December 2016, Dr. Prahalad prescribed Pamelor for her depression. (Tr. 459).

Sincavage began treating at Total Body Chiropractic in February of 2016 for her lower back and neck pain. (Tr. 513-31). Treatment notes indicated that Sincavage received gentle manual mobilization at each visit. (Id.) In March 2016, it was noted that Sincavage was showing slight improvement since her prior visit, and that she was progressing as expected. (Tr. 519). The treatment notes stated that Sincavage's problem was likely chronic, but with improvement in her condition she could see some improvement in her activities of daily living. (Tr. 519-20). She then treated at Czulada Chiropractic in May and June of 2016 for her back and neck pain. (Tr. 496-97). She received spinal mobilization treatment and home-based therapeutic exercises. (Tr. 496).

In April 2016, Sincavage was examined by Dr. Jay Willner, a state agency consultant, regarding her physical impairments. (Tr. 438). Dr Willner diagnosed her

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with vertebral basilar insufficiency, neck pain, left hip pain, vertigo, and syncope, and her prognosis was fair. (Tr. 440-41). He noted that Sincavage's neck and hip pain was largely a result of a motor vehicle accident she was involved in a few years prior, and that she occasionally had difficulty walking. (Tr. 438). Dr. Willner reported that the plaintiff was taking Valium at that time, and that she could perform all of her activities of daily living with some help or supervision. (Tr. 439). He opined that Sincavage could lift up to 20 pounds frequently and carry up to 10 pounds frequently; she could never climb stairs, ramps, ladders, scaffolds or balance, and occasionally stoop, kneel, crouch and crawl; and that she could perform activities like shopping, personal hygiene, use public transportation, and could ambulate without an assistive device. (Tr. 442-47).

Sincavage continued to treat with Dr. Prahalad in 2017. Dr. Prahalad noted that Sincavage was depressed and had neck pain, nausea, and left-hand weakness. (Tr. 605). Dr. Prahalad suggested that the plaintiff needed surgery on her left hand. (Id.) In October 2017, Dr. Prahalad noted that Sincavage was experiencing severe neck spasms, vertigo, memory loss, and poor concentration. (Tr. 604).

As for her mental impairments, Sincavage was examined by Dr. Elaine Everding, a state agency consultant, who performed a psychiatric examination on March 7, 2016. (Tr. 427). Sincavage reported to Dr. Everding that she was depressed "most of the time," she suffered from crying spells, fatigue, getting anxious, and

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having panic attacks. (Tr. 428). A mental status examination revealed that Sincavage was fluid in her speech, her thought process was coherent and goal-directed, she was somewhat anxious, and she had some difficulty with attention and concentration. (Tr. 429). Dr. Everding recommended individual psychological therapy and a psychiatric evaluation or follow up. (Tr. 431).

In April 2017, Sincavage began treating at Valley Counseling Associates for her depression and anxiety. (Tr. 463-84, 606-12). On her intake form, she noted a history of depression, memory problems, feelings of hopelessness and worthlessness, anxiety, and excessive crying. (Tr. 464-66). A mental status examination performed by Karen Hartt, MSW, indicated a normal grooming appearance, cooperative attitude, depressed mood but appropriate affect, normal speech and intact thought content, good judgment and good insight. (Tr. 468). The plaintiff began bi-weekly counseling sessions, where it was noted that much of her stress and anxiety stemmed from her family problems as well as her chronic pain. (Tr. 463-84). The therapy notes indicate that Sincavage's treatment plan including coping mechanisms, exercising, and maintaining a routine to cope with her depression and anxiety. (Id.) A psychological Services Consultation by Dr. Lenora Herrmann-Finn on May 2, 2017 diagnosed Sincavage with persistent depressive disorder but noted that she had no elevated levels of anxiety or depression. (Tr. 469).

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It is against this clinical backdrop that a hearing was held on this disability application on December 14, 2017, where Sincavage appeared and testified, along with her husband, and a Vocational Expert. (Tr. 89-141). Following this hearing, the ALJ issued a decision denying this application for benefits, finding that Sincavage remained capable of performing a range of light work jobs in the national economy in the representative occupations of a night cleaner, garment sorter, and assembler of small parts. (Tr. 33).

In that decision, the ALJ first concluded the Sincavage had met the insured status requirements of the Social Security Act from the date of her onset of disability through March 31, 2021 and had not engaged in any substantial gainful activity since her alleged onset date of disability on September 25, 2015. (Tr. 15). At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that Sincavage suffered from the following severe impairments: cervical spondylosis with shallow disc bulging and mild foraminal stenosis, thoracic spine degenerative changes,...

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