United States District Court, S.D. Indiana, Indianapolis Division
MONICA M. HOLT, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.
ENTRY ON JUDICIAL REVIEW
WALTON PRATT, JUDGE
Monica M. Holt (“Ms. Holt”) requests judicial
review of the final decision of the Commissioner of the
Social Security Administration (the
“Commissioner”), denying her application for
Social Security Disability Insurance Benefits
(“DIB”) under Title II of the Social Security Act
(the “Act”). For the following reasons, the Court
AFFIRMS the decision of the Commissioner.
January 4, 2013, Ms. Holt filed an application for DIB,
alleging a disability onset date of July 6, 2012. (Filing
No. 13-2 at 10.) Her claims were initially denied on May
8, 2013, and again on reconsideration. Id. Ms. Holt
filed a timely written request for a hearing and on July 15,
2014, a hearing was held before Administrative Law Judge
James R. Norris (the “ALJ”). Id. Ms.
Holt was present and represented by counsel. A medical
expert, Lee Fischer, M.D., a licensed clinical psychologist,
Don Olive, Ph.D., and vocational expert, Deborah A.
Dutton-Lambert (the “VE”) appeared and testified
at the hearing. Id. On August 7, 2014, the ALJ
denied Ms. Holt's applications for DIB. Id. at
7-24. On September 25, 2015, the Appeals Council denied Ms.
Holt's request for review of the ALJ's decision,
thereby making the ALJ's decision the final decision of
the Commissioner for purposes of judicial review.
Id. at 2-5. On November 24, 2015, Ms. Holt filed
this action for judicial review of the ALJ's decision
pursuant to 42 U.S.C. § 405(g). (Filing No. 1.)
time of her alleged disability onset date, Ms. Holt was
forty-six years old, and she was forty-eight years old at the
time of the ALJ's decision. She is a high school graduate
and has a past work history of being a claims support
specialist. 1999, Ms. Holt was diagnosed with human
immunodeficiency virus (“HIV”). (Filing No. 13-12
at 38.) At the time of her diagnosis she worked as a clerk
with CNA Insurance. Id. After experiencing
persistent pain in her neck and left shoulder, Ms. Holt had
three surgical procedures on her lymph nodes in an attempt to
reduce swelling and pain. (Filing No. 13-7 at 26; Filing No.
13-14 at 5; Filing No. 13-18 at 74.) In 2010, Ms. Holt
underwent her first procedure, and made a slow but full
recovery and eventually returned to work. (Filing No. 13-18
at 74.) Ms. Holt began to redevelop pain in her neck and left
shoulder, causing Ms. Holt to stop working on July 6, 2012.
(Filing No. 13-2 at 38.)
9, 2012, Ms. Holt underwent a second lymph node biopsy
procedure conducted by Mary A. Maluccio, M.D. (Filing No.
13-7 at 24-25.) Dr. Maluccio completed a disability insurance
form for Erie Indemnity Company, indicating that Ms. Holt
should stop working for ten days beginning on July 9, 2012
due to a condition that began on June 22, 2012. (Filing No.
13-16 at 41.) Ms. Holt never returned to work. On July 24,
2012, Ms. Holt's biopsy results suggested that she
suffered from necrotizing granulomas and histoplasmosis,
which caused difficulties with moving her neck and raising
her arms due to stiffness. (Filing No. 13-7 at 22.) To remedy
the stiffness, Ms. Holt attended twenty-six physical therapy
sessions, performing a variety of exercises designed to
strengthen and improve her range of motion. Id. at
August 21, 2012, Richard B. Kohler, M.D., evaluated Ms. Holt
and found that the surgical wounds in Ms. Holt's neck
healed well, but noted that she experienced pain when he
performed deep palpation in Ms. Holt's neck. (Filing No.
13-8 at 20-21.) Thereafter, Dr. Kohler completed a medical
questionnaire form, stating that Ms. Holt could not work
until September 17, 2012. (Filing No. 13-18 at 2-3.)
completing the physical therapy sessions, Ms. Holt returned
to Dr. Kohler on October 2, 2012. (Filing No. 13-7 at 88.)
She continued to face difficulties with shoulder mobility and
persistent pain in her left neck and shoulder. Id.
Ms. Holt was concerned about returning to her job, which
involved a lot of time in front of the computer, because
using a computer contributed to her shoulder pain.
Id. On physical examination, Ms. Holt showed small
palpable nodes at the base of her neck that were very tender
to even light palpation. Id. She could passively
elevate her arm to 90-degrees, although pressure over her
trapezius muscle and deltoid elicited pain. Id. The
examination further showed that Ms. Holt maintained equal
grip strength bilaterally, although gripping on the left
produced some discomfort. Id. at 89. Dr. Kohler
diagnosed Ms. Holt with HIV, left shoulder and neck pain,
histoplasmosis, depression, a history of intermittent
noncompliance with HIV treatment, and a past history of
October 23, 2012, Ms. Holt returned to Dr. Kohler. (Filing
No. 13-8 at 14.) Dr. Kohler found that there was limited
improvement in her left shoulder pain since the last visit
and that Ms. Holt concurrently developed a general pain
syndrome in her right shoulder and upper back area.
Id. at 15. After showing a limited range of motion
on examination, Dr. Kohler adjusted Ms. Holt's
medications and referred her to Alexander D. Mih, M.D., an
orthopedic surgeon. Id. at 15. On November 6, 2012,
Ms. Holt asked Dr. Kohler about disability benefits.
Id. at 12. Dr. Kohler informed Ms. Holt that he did
“not make disability judgments but rather provide
evidence to the social security disability administration,
” and explained “that disabling conditions must
be expected to last a year” before disability could be
Holt met with Dr. Mih on November 6, 2012. (Filing No. 13-7
at 98.) Her physical examination displayed a limited range of
motion on her left side, but no limitations on the right.
Id. Dr. Mih sent Ms. Holt for an electromyogram
(“EMG”) study that revealed relatively minor
radiculopathy. Id. at 347. After reviewing the
study, Dr. Mih concluded that the radiculopathy did not pose
a significant contribution to her discomfort, but recommended
the Ms. Holt see a neurosurgeon to determine if further
x-rays or scans are useful. Id.
Holt returned to Dr. Kohler on December 18, 2012, indicating
that she recently interviewed for a different job, but that
she could not currently work due to her health. (Filing No.
13-8 at 10.) Dr. Kohler examined Ms. Holt and determined that
she was in visible pain, there was some neck tenderness, and
Ms. Holt preferred not to rotate, flex, or extend her neck.
Id. Dr. Kohler concluded that Ms. Holt's neck
pain may have been caused by fibromyalgia. Id. at
January 31, 2013, neurologist Brent A. Huffman, M.D.,
conducted a neurology consultation with Ms. Holt.
Id. at 38-39. Ms. Holt reported significant
difficulty raising her left arm above 90-degrees.
Id. at 39. Physical examination revealed normal
muscle bulk and tone, normal reflexes and intact sensation in
her upper extremities, tenderness along the trapezius
muscles, and a painful range of motion in her left upper
extremity. Id. Dr. Huffman believed that the
radiculopathy shown by her EMG was incidental, not related to
Ms. Holt's severe pain, and advised that Ms. Holt obtain
an MRI of her cervical spine. Id. A MRI study of Ms.
Holt's cervical spine, conducted on February 6, 2013,
showed a small central disc protrusion resulting in mild
spinal stenosis. Id. at 6-7. The study further
revealed large heterogeneous masses in the supraclavicular
fossa in Ms. Holt's neck, likely representing necrotic
lymph nodes. Id.
February 7, 2013, Ms. Holt followed up with Dr. Huffman.
Id. at 65. Dr. Huffman reviewed the MRI study and
confirmed a diagnosis of histoplasmosis given the revelation
of five necrotic lesions in the left shoulder. Id.
On February 19, 2013, neurosurgeon Nicholas M. Barbaro, M.D.,
evaluated Ms. Holt pursuant to a referral from Dr. Kohler.
(Filing No. 13-14 at 5-6.) Dr. Barbaro concluded
that, while surgery posed a risk of further nerve damage, Ms.
Holt showed progressive brachial plexopathy and without
surgery she may lose more plexus function. Id.
April 5, 2013, J. Nathan Smith, M.D., examined Ms. Holt and
determined that Ms. Holt showed a full, or nearly full, range
of motion in all areas except her shoulders and cervical
spine. (Filing No. 13-13 at 33-35.) On May 7, 2013, M. Ruiz,
M.D., reviewed Ms. Holt's medical record and concluded
that Ms. Holt was capable of sitting for six ...