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Breitmeyer-Schaal v. Colvin

United States District Court, D. Vermont

December 6, 2016

CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.


          William K. Sessions III District Court Judge.

         Plaintiff Ariana Breitmeyer-Schaal brings this action pursuant to 42 U.S.C. § 405(g) of the Social Security Act, requesting review and remand of the decision of the Commissioner of Social Security denying her applications for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). Pending before the Court are Plaintiff's motion to reverse the Commissioner's decision (ECF No. 17) and the Commissioner's motion to affirm the same (ECF No. 25). For the reasons stated below, Plaintiff's motion is DENIED and the Commissioner's motion is GRANTED.


         Plaintiff applied for DIB and SSI on June 1 and June 6, 2011, respectively. Both applications were denied initially and upon reconsideration. An ALJ issued an unfavorable decision on January 16, 2013. The SSA Appeals Council subsequently declined review, thus rendering the ALJ's decision the final decision of the SSA Commissioner. Plaintiff is proceeding in this case pro se.

         I. Plaintiff's Medical History

         On May 31, 2008, at the age of 23, Plaintiff underwent Cesarean section (C-section) surgery. Plaintiff reports that she was fully functional before the surgery, but had not worked since 2006 because she was attending school. Adhesions resulting from the C-section have allegedly left her in severe pain and unable to exert physically. Plaintiff also claims that her pain impedes her ability to concentrate.

         In the months following her C-section, Plaintiff began developing radiating pain in the right side of her abdomen. On March 31, 2009, she sought care at the Emergency Room at Stony Brook Medical Center in New York. On April 23, 2010, after moving to Vermont, she again sought Emergency Room services because of her pain. At that time she was prescribed narcotics and advised to make an appointment with an OB/GYN.

         On April 27, 2010, Plaintiff met with Dr. Kym Boyman, who became her treating OB/GYN. Dr. Boyman performed an ultrasound but was apparently unable to identify the source of the pain, ruling out a prior ovarian cyst. In September 2010, Plaintiff required immediate surgery due to an ectopic pregnancy. Dr. Boyman performed the surgery and discovered multiple adhesions of the uterus and the abdominal wall. While Dr. Boyman was able to both photograph and cut through some of the adhesions, the surgery was ended because Plaintiff began to suffer blood loss.

         During a September 27, 2010 post-operative call from Dr. Boyman's office, Plaintiff reported that she was still sore. During an October 7, 2010 call, Plaintiff again reported pain while doing certain activities such as grocery shopping. Shortly thereafter she reported that she was moving from one residence to another, and that her incision caused her pain while she was packing and unpacking her belongings.

         During a November 2010 post-surgical follow-up, Dr. Boyman suggested that internal stretching from the adhesions was causing myofascial pain, meaning that the muscles surrounding the adhesions were acting in ways that could cause additional pain. Plaintiff was not taking medication at that time, and reported feeling well overall.

         In December 2010, Plaintiff had an initial visit with primary care physician Dr. Terry Cantlin. During that visit, Plaintiff mentioned increased lower abdominopelvic discomfort. A subsequent ultrasound showed a cyst on her right ovary. In March 2011, Plaintiff visited gynecologist Beth Vermont, M.D, who noted abdominal tenderness. Dr. Vermont suggested hormonal therapy to shrink the cyst, but Plaintiff believed the therapy might aggravate her migraines. Dr. Vermont also suggested a diagnostic laparoscopy to try to identify the source of pain.

         In May 2011, Plaintiff again complained to Dr. Boyman of significant pain, at which time Dr. Boyman noted that pelvic pain was prohibiting Plaintiff from working. Plaintiff applied for SSDI in June 2011, and Dr. Boyman wrote a letter supporting the application, stating that Plaintiff was “currently unable to do any work due to significant pain.” Dr. Boyman also noted her “hope and expectation that this will not be a permanent condition.” Plaintiff contends that Dr. Boyman's notes make clear that any optimism about possible improvement was based upon the expected success of physical therapy for the myofascial pain, and that physical therapy was not expected to address the pain resulting from the underlying adhesions.

         In July 2011, Plaintiff met with gynecologist Dr. Tanya Kalmar. During that exam, Dr. Kalmar noted that Plaintiff's abdomen was not tender and that she had no guarding or rigidity. Plaintiff was also estimated to be 13 weeks pregnant.

         In November 2011, state agency physician Dr. Carl Runge reviewed Plaintiff's medical records. Dr. Runge determined that in an eight-hour workday, Plaintiff could sit for six hours and lift and carry up to ten pounds. He saw no limitations in her ability to use her hands, climb stairs, balance, kneel, crouch, or crawl. Dr. Runge also opined that Plaintiff would need to change positions for five minutes every hour to relieve pain.

         In December 2011, Plaintiff met with gynecologist Dr. Lawrence Slocki. Dr. Slocki reviewed her medical records, including the pictures of her adhesions. Although he noted previous pelvic pain, he reported that Plaintiff did not report having much pain at that time. Aside from Plaintiff's obesity, Dr. Slocki concluded that the physical examination was unremarkable.

         Plaintiff had another C-Section on March 15, 2012. The operating physician, Dr. Dina Levin, again removed some of Plaintiff's adhesions. In April 2012, Plaintiff complained of abdominal pain and requested a refill of her oxycodone prescription. Dr. Levin noted that Plaintiff seemed “awfully well” and that her wound was healing. Approximately one week later, Plaintiff again complained of pain, but Dr. Levin did not believe that the pain was from the adhesions. Dr. Levin suggested physical therapy, and expressed concern that ...

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