Christians v. Saul

JEREMY S. CHRISTIANS PLAINTIFF v. ANDREW M. SAUL,¹ Commissioner, Social Security Administration DEFENDANT

CIVIL NO. 5:19-CV-5179

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF ARKANSAS FAYETTEVILLE DIVISION

July 23, 2020

MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

Plaintiff, Jeremy s. Christians, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying his claim for supplemental security income (SSI) under the provisions of Title XVI of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision. See 42 U.S.C. § 405(g).

I. Procedural Background:

Plaintiff protectively filed an application for SSI on October 25, 2016, alleging an inability to work since September 4, 2010, due to the following: degenerative disc disease in neck; left leg and hip injury, pain and issues; neck pain and/or pinched nerve; nerve pain; left arm numbness; migraines; chronic pain; surgery for rod in leg; post-traumatic stress disorder (PTSD); anxiety; and depression. (Tr. 54-55, 72-73). An administrative hearing was held onMay 15, 2018. (Tr. 38-63). Plaintiff was present and testified. (Tr. 42-62). A vocational expert (VE) also testified. (Tr. 58-63).

In a written opinion dated December 17, 2018, the ALJ found that Plaintiff had the following severe impairments: degenerative disc disease (degenerative disorder of the back - discogenic and degenerative) and depressive disorder. (Tr. 17). However, after reviewing the evidence in its entirety, the ALJ determined that the Plaintiff's impairments did not meet or equal the level of severity of any listed impairments described in Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr. 17-19). The ALJ found Plaintiff retained the residual functional capacity (RFC) to perform light work as defined in 20 C.F.R. 416.967(b), except the Plaintiff could climb ramps and stairs occasionally; climb ladders, ropes, and scaffolds occasionally; and balance, stoop, kneel, crouch, and crawl occasionally. In addition, Plaintiff was limited to work where interpersonal contact was incidental to the work performed; the complexity of tasks was learned and performed by rote with few variables and little judgment; and the supervision required was simple, direct, and concrete. (Tr. 19-27). With the help of the VE, the ALJ determined that Plaintiff was unable to perform his past relevant work as a poultry farm laborer, forklift operator, and frontend loader driver. (Tr. 27). Considering Plaintiff's age, education, work experience, and RFC, the ALJ determined that there were jobs that existed in significant numbers in the national economy that Plaintiff could perform, such as a can filling closing machine tender, a power screw driver operator, and a compression molding machine tender. (Tr. 28). Ultimately, the ALJ concluded that Plaintiff had not been under a disability within the meaning of the Social Security Act since October 25, 2016, the date the application was filed. (Tr. 28).

Subsequently, Plaintiff requested a review of the hearing decision by the Appeals Council, which denied that request on July 25, 2019. (Tr. 1-6). Plaintiff filed a Petition for Judicial Review of the matter on September 19, 2019. (Doc. 2). Both parties have submitted briefs, and this case is before the undersigned for report and recommendation. (Docs. 12, 13).

The Court has reviewed the transcript in its entirety. The complete set of facts and arguments are presented in the parties' briefs and are repeated here only to the extent necessary.

II. Evidence Submitted:

At the May 15, 2018, hearing before the ALJ, Plaintiff testified that he was born in 1971; that he was a high school graduate; and that he had completed two years of college courses. (Tr. 42). Testimony also showed that Plaintiff's past work consisted of a poultry farm laborer, a forklift operator, and a frontend loader. (Tr. 48-51, 59).

Prior to the relevant time period, Plaintiff was treated for hip and femur injuries sustained in an incident while in jail; chronic pain in the left hip; neck and chest pain; chronic left leg pain; osteoarthritis in pelvic region and thigh; an episode of syncope; insomnia; PTSD; anxiety; depression; treatment for symptoms of suicidal ideation; and a period of inpatient treatment for onset of alcohol-induced mood disorder during intoxication. Plaintiff was also treated for cervical radiculopathy with injections and physical therapy.²

On November 9, 2016, Plaintiff saw Dr. Regina Thurman for a follow up on his hip and leg pain. Plaintiff reported that his medication was currently working well but that his insurance had become inactive. As a result, he did not have a primary care physician and hadtrouble getting in to see Dr. Thurman. Plaintiff also reported that he fell off a ladder recently and suffered bruising from the fall. He reported that his medications allowed him to perform his activities of daily living. (Tr. 396). Plaintiff's gait was abnormal, and he was unable to stand without difficulty. (Tr. 398). He was assessed with chronic pain, hip pain, and osteoarthritis of the pelvic region and thigh. (Tr. 398).

On November 14, 2016, Plaintiff saw Chelsie Harper, LMSW, at Ozark Guidance Center for a ninety-day review. (Tr. 450). Notes indicate Plaintiff had shown some improvement and progress toward his goal through individual therapy. (Tr. 453). Ms. Harper indicated that Plaintiff was, at the most, moderately incapacitated by anxiety, activities of daily living, physical condition, and job performance problems. (Tr. 456).

On November 22, 2016, Plaintiff saw Dr. Ester Salvador at Ozark Guidance Center. (Tr. 458). Plaintiff reported a history of depression; the loss of his wife after she had an affair; and that he was filing for disability after his leg injury and neck pain. Plaintiff reported feelings of hopelessness, trouble sleeping, poor appetite, poor self-esteem, and feelings of restlessness. Plaintiff stated that the past week was really challenging for him and that life was dragging him down. Plaintiff reported missed therapy sessions due to transportation issues. (Tr. 458). Plaintiff's history included having been previously discharged from therapy for missing sessions; having been under a no-contact order, which he violated and served four months jail time; having violated the order a second time, but without jail time; and having become suicidal after the second incident of violating the no-contact order. Plaintiff reported depression of 7/10 that day, activity of 5/10 and irritability and anger at a 3/10. (Tr. 459). Plaintiff's psychiatric examination showed the following: casually groomed in appearance, thin build, cooperative behavior, average eye contact, clear speech, logical thoughts, full affect, depressed and anxiousmood, oriented to person, place, time, and circumstance, attentive to evaluation, impaired judgment and insight, normal gait, and fair strength. (Tr. 462). Plaintiff was diagnosed with major depressive disorder and generalized anxiety disorder. (Tr. 462). Plaintiff's irritability and anger were improved and were not present that day. Dr. Salvador instructed Plaintiff to continue his medication, attend counseling, and eat a healthy diet. She noted that Plaintiff's depression, anxiety, irritability, and anger were in remission. (Tr. 463).

On November 28, 2016, Plaintiff returned to see Ms. Harper at Ozark Guidance Center for individual therapy. (Tr. 698). Therapy notes indicate Plaintiff had continued to show stability and increased insight into how his poor relationship boundaries and unhealthy dynamics had negatively impacted him. His prognosis was good. (Tr. 699).

On December 8, 2016, Plaintiff returned for another therapy session with Ms. Harper. Ms. Harper noted that Plaintiff continued to show stability during the session; that he finished his mandatory domestic violence classes; and that he continued to learn and grow. His prognosis continued to be good. (Tr. 702).

On January 6, 2017, Plaintiff visited physician assistant Lindsey Smallridge at NWAMC Orthopedics for a consultation for his hip pain. (Tr. 810). Plaintiff reported pain since his injury but also stated that his pain was better than it had been the last few months. He struggled to stay in one position too long and felt that the "bolt" inside his hip was very tender to touch. (Tr. 810). Plaintiff's physical examination showed that he was not in any acute distress; that his incision had healed well with no sign of infection; that he had good lower extremity strength with manual testing; and decent range of motion at the hip. (Tr. 811). An x-ray of Plaintiff's hip showed his hip hardware to be intact and no sign of arthritis in the hipjoint. (Tr. 812). Dr. Smallridge explained that Plaintiff's "hip joint itself looked quite good so he would not be a surgical candidate for hip replacement" at the time. His only surgical option would be hardware removal; however, there would be no guarantees of his limitations or pain level without the hardware. (Tr. 812). Notes indicate that Plaintiff did not want to proceed with surgery to remove the hardware. (Tr. 814).

On January 9, 2017, Plaintiff attended therapy with Allyson Smolinski, LMSW, also at Ozark Guidance Center. Plaintiff discussed his background, past trauma, and depressive symptoms. He also reported that he felt he had made significant progress with Ms. Harper. (Tr. 705).

On February 2, 2017, Plaintiff saw Dr. Thurman for a follow up on his left hip and left leg pain. (Tr. 670). Notes confirmed that orthopedics did not recommend surgery. Plaintiff's medications were working well overall, and they allowed him to perform his activities of daily living. Plaintiff was taking ibuprofen, Percocet, and tramadol. Plaintiff reported having no side effects...