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Holt v. Colvin

United States District Court, S.D. Indiana, Indianapolis Division

December 2, 2016

MONICA M. HOLT, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.



         Plaintiff 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.

         I. BACKGROUND

         A. Procedural History

         On 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.)

         B. Factual Background

         At the 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.)

         On July 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 31-37.

         On 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.)

         After 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 histoplasmosis. Id.

         On 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 awarded. Id.

         Ms. 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.

         Ms. 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 11.

         On 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.

         On 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.

         On 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 ...

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