CANDELARIA COSTA v. COMMISSIONER OF SOCIAL SECURITY

CourtDistrict Court, D. New Jersey
DecidedApril 23, 2021
Docket3:19-cv-13389
StatusUnknown

This text of CANDELARIA COSTA v. COMMISSIONER OF SOCIAL SECURITY (CANDELARIA COSTA v. COMMISSIONER OF SOCIAL SECURITY) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
CANDELARIA COSTA v. COMMISSIONER OF SOCIAL SECURITY, (D.N.J. 2021).

Opinion

NOT FOR PUBLICATION UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

SONIA CANDELARIA COSTA

Plaintiff, v. Civil Action No. 19-13389(FLW)

COMMISSIONER OF SOCIAL SECURITY, OPINION

Defendant.

WOLFSON, CHIEF JUDGE: Sonia Costa (“Plaintiff”) appeals from the final decision of the Acting Commissioner of Social Security, Andrew Saul (“Defendant”), denying Plaintiff disability benefits under Title II of the Social Security Act (the “Act”). After reviewing the Administrative Record, the Court finds that the Administrative Law Judge's (“ALJ”) decision was based on substantial evidence and, accordingly, it is AFFIRMED. I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY Plaintiff was born on November 2, 1966, and was 45 years old on the alleged disability onset date of August 8, 2012. Administrative Record 41 (hereinafter “A.R.”). Plaintiff has a tenth- grade educational level. A.R. 41. Prior to her alleged disability, Plaintiff worked as secretary. A.R. 42. On September 3, 2015, Plaintiff applied for disability insurance benefits for her occipital neuralgia (a condition which causes pain in the upper neck and behind the head), depression, anxiety, hypertension, palpations, migraine headaches, blurred vision, gastroesophageal reflux disease (“GERD”), leaky heart valve minor, and right leg pain. A.R. 54, 68, 184-90. Plaintiff’s claims were denied on January 18, 2016, and again upon reconsideration on April 12, 2016. A.R. 15. Following the denials, Plaintiff requested a hearing, which was held on May 3, 2018, before ALJ Theodore Kim. A.R. 14. ALJ Kim determined that Plaintiff was not disabled and denied her claims for disability insurance benefits. A.R. 29. Plaintiff requested review by the Appeals

Council and the request was denied on April 3, 2019. A.R. 1-6. Thereafter, on June 4, 2019, Plaintiff filed the instant appeal. A. Review of the Medical Evidence a. The Evidence Reviewed by the ALJ The medical record detailing Plaintiff’s alleged disabling impairments is extensive. On August 2, 2012—six days before Plaintiff’s alleged disability onset date—Manish Viradia, M.D., examined Plaintiff, who complained of frequent “moderate to severe” headaches and severe neck pain. A.R. 652. Plaintiff stated to Dr. Viradia that she did not get enough sleep because of her migraine headaches and cared for a “very young child.” Id. Plaintiff also claimed fatigue, vertigo, lightheadedness, and dizziness. A.R. 653. Dr. Viradia’s report states that Plaintiff denied neck

stiffness, neck tenderness, difficulty concentrating, memory difficulties, muscular weakness, anxiety, and depression. A.R. 653-54. Generally, Dr. Viradia observed that Plaintiff was in no acute distress, had a normal posture, and appeared well nourished. A.R. 654. Examining her neck, Dr. Viradia noted a normal range of motion, no tenderness, or deformities. Id. That same report described Plaintiff’s heart as normal with a regular heart rate and rhythm, and no murmurs. Id. Examinations of Plaintiff’s right leg were normal. A.R. 655. On August 10, 2012, Dr. Viradia, again, examined Plaintiff and observed she suffered from increased headache and neck pain, poor “postural endurance, severe tenderness in her spine, decreased strength in her shoulder and elbows, with decreased range of motion that limited her ability to carry objects, drive, sleep, conduct work on a computer and perform daily home activities. A.R. 659-60. He scheduled Plaintiff for two to three visits for four weeks for pain management, therapeutic exercises, postural stabilization, soft tissue mobilization, stretching, and a home exercise program. A.R. 660.

On August 15, 2012, MRIs performed by Mark Malzberg, M.D., on Plaintiff’s spine and brain were reported as “unremarkable for the age of the patient” and “normal.” A.R. 661. Dr. Malzberg’s reports noted Plaintiff’s “well aligned” and “normal” vertebrae. Id. Plaintiff also saw Dipak Pandya, M.D., on September 27, 2012, who noted that Plaintiff complained of neck pain. A.R. 669. Dr. Pandya suggested injection therapy, but Plaintiff preferred pain medications. Id. Dr. Pandya prescribed her Primera and Flexeril. Id. Dr. Pandya’s report noted Plaintiff’s anxiety and nervousness, but that she “does not have [a] significant major medical problem.” A.R. 664. The doctor later noted that physical therapy yielded “improvement” and was “helping.” Id. Dr. Pandya opined that Plaintiff’s headaches were “more consistent with common migraine.” A.R. 668. Plaintiff was referred to physical therapy for her spine pain. Id.

Records from Plaintiff’s physical therapy at Kessler Rehabilitation Center spanned from October 2012 through April 2013. A.R. 430-57. Those records detailed her cervical spine and headache complaints which Plaintiff stated stemmed from a fall down the stairs. A.R. 430. An October 2012 report noted that Plaintiff independently dressed herself “without difficulty”; had difficulty driving and “turning her head to the right”; could perform light housework; and limited her to lifting light weights occasionally. Id. The physical therapy report from December 2012 compared Plaintiff’s range of motion with the October 2012 report. A.R. 436. It shows that Plaintiff’s spine extension and flexion remained at 100%. Id. Rotation in Plaintiff’s spine and her ability to bend at her side improved from 75% to 90%. Id. MaryBeth Campbell, P.T., noted that the “[o]verall rehabilitation potential is good.” A.R. 437. Plaintiff’s physical therapy results during the period of January through April 2013 remained consistent with earlier reports. A.R. 438-54. Plaintiff next saw Dr. Pandya on July 18, 2013, who reported that Plaintiff stopped physical

therapy and that her symptoms were “increasing neck pain, some left upper extremity pain, and shoulder pain.” A.R. 670. Physical therapy, it was noted, “did help her.” Id. Dr. Pandya opined that Plaintiff’s migraines were “significantly better,” but that she may have increasing pain with side-to-side neck movements. Id. Plaintiff did not see Dr. Pandya again until March 2014, when Dr. Pandya reported that “patient states she is improving.” A.R. 675. Dr. Pandya also noted that Plaintiff’s daily headaches continued, but had no additional complaints. Id. Dr. Pandya noted an “underlying generalized anxiety disorder,” but observed that Plaintiff “had been working [and] functioning well with limited amount of pharmacological management.” A.R. 679. Dr. Pandya suggested nerve block or injection therapy if “current management” was not helping; Plaintiff maintained that she was

“not ready for that type of intervention” and only sought physical therapy. Id. Another MRI was performed on March 19, 2014, which came back normal. A.R. 682. In November 2015, Plaintiff saw examining physician Aleya Salam, M.D., who reviewed Plaintiff’s x-rays and MRIs, and characterized them as “unremarkable,” but noted that Plaintiff “has signs and symptoms of Fibromyalgi[a].” A.R. 701-04. Dr. Salam reported that Plaintiff’s cervical spine appeared normal with a normal range of motion, but observed Plaintiff’s “mild paraspinous muscle tenderness.” A.R. 703. Dr. Salam recommended another cervical spine MRI, which Laura Klein, M.D., performed on November 18, 2015. A.R. 706. Dr. Klein’s report indicated the MRI was normal and observed that her spine had an “[o]therwise … similar appearance to the prior” MRI of Plaintiff’s spine. Id. The following month, Dr. Pandya diagnosed Plaintiff with Fibromyalgia. A.R. 711. As for Plaintiff’s complaints of blurred vision, Plaintiff was treated by Gerald Batt, M.D., in September 2012, March 2014, and October 2014. A.R. 410- 13. Dr. Batt noted Plaintiff’s migraines, and occipital neuralgia. He also commented that Plaintiff

has contact lenses but does not wear them and wrote “dry” and “itchy,” and that Plaintiff uses glasses instead but does not need them to read. Id. In March 2014, Dr.

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CANDELARIA COSTA v. COMMISSIONER OF SOCIAL SECURITY, Counsel Stack Legal Research, https://law.counselstack.com/opinion/candelaria-costa-v-commissioner-of-social-security-njd-2021.