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Coffman v. Berryhill

United States District Court, E.D. Missouri, Eastern Division

August 29, 2017

BILLY DEWAYNE COFFMAN, Plaintiff,
v.
NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          JOHN M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE.

         This is an action under Title 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner denying the applications of Billy Dewayne Coffman (“Plaintiff”) for disability insurance benefits under 42 U.S.C. §§ 401 et seq. Plaintiff has filed a brief in support of the Complaint. (ECF No. 19) Defendant Commissioner Nancy A. Berryhill has filed a brief in support of the Answer (ECF. No. 24) The parties have consented to the jurisdiction of the undersigned United States Magistrate Judge pursuant to Title 28 U.S.C. § 636(c) (Doc. No. 7).

         Substantial evidence supports the Commissioner's decision, and therefore it is affirmed. See 42 U.S.C. § 405(g).

         I. Procedural History

         On January 26, 2015, Plaintiff filed an application for disability benefits, claiming that his disability began on April 30, 2013. (Tr. 13) Plaintiff's claims were denied upon initial consideration in a decision issued March 5, 2015.[2] (Tr. 201-12) Plaintiff then requested a hearing before an Administrative Law Judge (“ALJ”).

         Plaintiff appeared at the hearing with counsel on September 23, 2015, and testified concerning the nature of his disability, his daily activities, functional limitations, and past work. (Tr. 170-93) The ALJ also heard testimony on that date from Barbara Meyers, a vocational expert (“VE”) who offered opinion testimony as to Plaintiff's ability to secure other work in the national economy, based upon several hypothetical questions. (Tr. 194-200) The ALJ issued a decision on November 25, 2015 (“the Decision”), finding that Plaintiff was not disabled. (Tr. 13-24)

         Plaintiff then sought review of the ALJ's decision before the Appeals Council of the Social Security Administration. (Tr. 8) The Appeals Council received additional medical records from the St. Louis Veterans Administration (“VA”) Medical Center.[3] (Tr. 6) On March 8, 2016, the Appeals Council denied review of Plaintiff's claims, (Tr. 1-5), making the November 2015 decision of the ALJ the final decision of the Commissioner. Plaintiff has therefore exhausted his administrative remedies, and his appeal is properly before this Court. See 42 U.S.C. § 405(g).

         In his brief to this Court, Plaintiff raises the following four arguments: (1) that the ALJ “failed to properly evaluate Plaintiff's pain complaints” and therefore formulated an RFC not supported by substantial evidence; (2) that the ALJ did not adequately account for Plaintiff's claimed insomnia in formulating the RFC; (3) that the ALJ improperly discounted the opinion of Plaintiff's treating psychologist; and (4) that the RFC is “simply conclusory and does not contain any rationale or reference to the supporting evidence.” (ECF No. 19)

         II. Plaintiff's Disability and Function Reports and Hearing Testimony

         In his disability paperwork, Plaintiff indicated that he was suffering from radiculopathy in both legs, residual chronic lower back pain from a lumbar strain, patellofemoral syndrome in both knees, tension headaches, post-traumatic stress disorder and depression. (Tr. 333) Plaintiff completed high school and one year of college. (Tr. 334) He listed a job history over the last 15 years of military service in logistics, truck driving, corrections officer, mining laborer, port-o-potty delivery, assembly for a retail store, box assembly and shipping and receiving.[4] (Tr. 342-51)

         Plaintiff indicated that he lived in a house with his wife. (Tr. 352) He described some problems with personal care, mostly involving bending over or reaching his feet. (Tr. 353) Plaintiff indicated that he performed some household work (doing the dishes, doing laundry, sweeping and mopping), as well as cooking and helping take care of the cat. (Tr. 353-54). He stated that he had to take a break while washing dishes, due to an inability to stand for the entire time. (Tr. 322)

         Plaintiff stated he was able to go out once day, drive without need of accompaniment, and shop for a wide variety of items. (Tr. 355) He stated that he was able to handle basic financial affairs, such as paying bills, using a checkbook and handling a savings account. (Id.) Plaintiff listed his hobbies as watching television as well as hiking, fishing, hunting and carpentry, although he is unable to do any of these except watch television due to his conditions.[5](Tr. 325, 356) Plaintiff stated that he formerly engaged in social activities with friends 3-4 times per week, although this has tailed off to telephone conversations, going to church every other weekend and visiting his mother once a month. (Tr. 326, 356)

         Plaintiff reported that he could pay attention for up to 10 minutes at a time, had issues finishing what he started, had no problem following written instructions but had difficulties with spoken instructions.[6] (Tr. 326) He also stated that he got along fine with authority figures and handled changes in routine well, but did not handle stress well and had a “fear of crowds.” (Tr. 327) Plaintiff stated that his conditions affected his ability to concentrate and complete tasks, due to the pain.[7] (Tr. 326, 357)

         Plaintiff was also interviewed on February 10, 2015. (Tr. 329-331) The interviewer noted that Plaintiff walked with the assistance of a cane, and that he “had some trouble focusing due to his medications.” (Tr. 330)

         During the September 2015 hearing before the ALJ, Plaintiff testified that his back and leg problems were the biggest obstacle to his ability to work. (Tr. 179-80) He stated that he was unable to continue in his last employment as a truck driver because the pain was too severe, and he was unable to drive if he took his pain medication. (Tr. 179) He described the pain as “like a searing needle going into a blister” which is always present in his lumbar spine, with three to four episodes per day of shooting pains “like electricity going down the back of [his] leg and into [his] toes.” (Tr. 180-81)

         Plaintiff stated that he had been prescribed the cane by the VA Medical Center and he uses it for stability while walking, although he can stand in place without the cane. (Tr. 182) Plaintiff claimed he cannot stoop or crouch, but can kneel to retrieve things from the floor (albeit with discomfort). (Tr. 183) He estimated that he could usually lift and carry up to eight pounds. (Id.) Plaintiff also testified that he could stand for 10-15 minutes at a time, walk no more than 100 yards, and sit for between half an hour to an hour before needing to move. (Tr. 183-84) He estimated the pain level in his back at three to five (out of ten) on a good day, and between six and eight on a bad day. (Tr. 188)

         In terms of treatment for the back and leg pain, Plaintiff stated that he takes medication, and uses a transcutaneous electrical nerve stimulation (“TENS”) unit daily and a prescribed traction table twice a day. (Tr. 186) He also claimed to have had approximately five steroid injections, with pain relief lasting less than two days for most. (Id.) At the time of the hearing, Plaintiff had tried physical therapy, and had been prescribed more physical therapy by a neurosurgeon he had consulted. (Tr. 187) Plaintiff claimed that his medications make him sleepy, and that he naps for three to four hours during the day. (Tr. 190-91)

         Plaintiff also testified at the hearing regarding his psychological health. He described having “bouts of sadness” and “crying spells” every day. (Tr. 191-92) He also described feeling “trapped” and feeling the need to escape if in a crowded space. (Tr. 192) Plaintiff also testified that he has “problems with concentration, ” such as entering a room and forgetting what he went in there to get. (Id.)

         III. Medical Records

         The administrative record before this Court includes voluminous medical records from two VA facilities, reports from non-VA providers incorporated into the VA's system, and a non-VA rehabilitation center. The Court has reviewed the entire record. The following is a summary of pertinent portions of the medical records relevant to the matters at issue in this case.

         A. Physical Disorders

         The earliest records included in the transcript are from April 2012, which notes that Plaintiff suffers from chronic back pain. (Tr. 820-821) On December 12, 2012, Plaintiff was seen at the John Cochran VA Medical Center, primarily for pain and inflammation under his jaw. (Tr. 766-67) During this visit, Plaintiff complained that he had noticed pain in his right upper back, as well as muscle cramping in his lower legs, developing over the previous month. (Tr. 766) He stated that he would sit from 12-20 hours. (Id.) Otherwise, he described himself as “doing great.” (Id.)

         On May 31, 2013, Plaintiff went to the urgent care department at the John Cochran VA when his left foot was injured by a log falling on it. (Tr. 747) He informed the staff that he examined the foot at the time of the accident, and then “worked for two more hours.” (Tr. 750) Three x-rays of the foot revealed no acute injuries, and the report did not note any abnormalities. (Tr. 854-55)

         Plaintiff was again seen at the John Cochran VA on July 16, 2013 in relation to chronic lower back pain and migraine headaches. (Tr. 739-45) Plaintiff underwent x-ray examination of his lower back and spine, which showed “[v]ery early changes of degenerative arthritis” but no narrowing of the intervertebral disk spaces and no acute bone or joint changes noted when compared to a 2011 set of x-rays. (Tr. 401) In response, his medications were changed to include Fiorcet (an acetaminophen/caffeine/barbiturate medication often used for headaches), tizanidine (a muscle relaxant) and tramadol (an opioid pain medication). (Tr. 740-741) Despite this change in medication, Plaintiff called the VA to get a referral to a chiropractor for “unbearable” back pain. (Tr. 736)

         On August 18, 2013, nearly four months after his claimed onset of total disability, Plaintiff was seen at an emergency room due to a hand injury incurred while fishing. (Tr. 731-35)

         On August 20, 2013, he presented back to John Cochran for complaints of left foot soreness and occasional swelling, as well as increased back pain. (Tr. 722-30) No changes to his medication or treatment were made. (Tr. 730) He stated that the tizanidine worked much better than his previous muscle relaxant, that the Fiorcet had worked well, and that as a result of the Fiorcet he had only taken one or two tramadol in the month since it was prescribed. (Tr. 722) He stated that he only used the TENS unit “once in a while.” (Id.) On his Patient Health Questionnaire 9 (PHQ-9), Plaintiff's score fell into the “no depression” range. (Tr. 726)

         On September 9, 2013, Plaintiff underwent an MRI of his spine. (Tr. 399-400) The test was essentially normal, except for a “mild central posterior bulge of the L5-S1 disc without obvious herniation or neural impingement.” (Tr. 399)

         Plaintiff underwent a cardiac workup on September 17, 2013, due to an elevated heart rate during his PT evaluation. (Tr. 700) The tests showed a normal heart size, no infiltrates and no effusions. (Tr. 398) Plaintiff was prescribed a low dose of metoprolol. (Tr. 701)

         Plaintiff was seen on a follow-up visit for his pain on October 5, 2013. (Tr. 684) He stated that the tramadol was effective when taken as needed. (Tr. 691) Plaintiff had been going to a chiropractor and needed an order for additional visits. (Tr. 684) These visits were denied, and Plaintiff was later informed that “neurosurgery feels that he has nothing on the MRI that is not age related changes and no further treatment is warr[a]nted at this time[.]” (Tr. 687)

         On February 27, 2014, Plaintiff had both knees x-rayed, and was evaluated by Dr. Edward Kreulen, M.D., to determine Plaintiff's eligibility for an increase in his service-related disability rating. (Tr. 396-397; 1071-95) On the x-rays, no osseous or adjacent soft tissue abnormalities were found in either knee. (Tr. 396-397) Plaintiff was able to bend his knees to the full 140 degrees, with pain starting at 130 degrees. (Tr. 1085) Plaintiff reported that after repetitive use, both knees have pain, swelling, disturbance of locomotion and interference with sitting, standing and weight-bearing. (Tr. 1087) He also stated that if he “had to squat more than an hour in the course of the day” there would be “significant limitation in his range of motion.” (Id.) Objective examination revealed no muscular weakness or instability, and no indication of recurrent patellar subluxation or dislocation. (Tr. 1087-1090) While Dr. Kreulen opined that it was “feasible” that during flare-ups or after repeated use over time Plaintiff's knees could have significantly limited functional ability, he was unable to form an opinion as to what extent such limitations might exist. (Tr. 1091) As to his back, Plaintiff was observed as having a range of motion of 85 degrees forward flexion (with objective evidence of pain beginning at 80 degrees), the full 30 or more degrees of extension (with pain beginning at 25 degrees), 25 degrees of right lateral flexion, 30 degrees of left lateral flexion and a full range of motion for lumbar rotation. (Tr. 1074-75) He was noted as having an antalgic gait and palpable muscle spasms. (Tr. 1076) He had full muscle strength and normal deep-tendon reflexes, with normal sensation to light touch until his feet, where sensation is decreased. (Tr. 1077-78) His straight-leg raise test was negative for both legs. (Tr. 1078) Plaintiff was noted as having “mild” paresthesia or dysesthesia and numbness in both legs, and mild radiculopathy. (Tr. 1078-79) Plaintiff also reported to Dr. Kreulen that his tension headaches were “becoming more frequent and had been increasing in intensity over the past 2-3 years.” (Tr. 1093)

         On April 12, 2014, Plaintiff had a follow-up exam. (Tr. 606) He reported that the Fiorcet was no longer working to address his headaches, and that he had stopped taking the tramadol due to his other medications. (Tr. 612) He also reported that his service-related disability percentage had been raised from 50% to 80%, and that he “is wanting to try for 100% for his chronic arthralgias.” (Tr. 606) Plaintiff was prescribed naproxen for his pain and atorvastatin for his cholesterol. (Tr. 608-09)

         On September 4, 2014, Plaintiff was seen for a general follow-up. (Tr. 580) He stated that in the last two months he had increased lumbar pain, that the pain was a constant 8/10 in intensity, and was radiating down both legs. (Tr. 581) The staff physician who examined Plaintiff noted that he appeared uncomfortable sitting, displayed difficulty “taking even a few steps and getting up from a chair so as not to strain his back as much.” (Tr. 582-83). He also noted bouts of nausea, difficult urination and urine retention. (Tr. 581) Plaintiff stated that he was not sleeping well due to the pain. (Tr. 585) Plaintiff was given an injection of methylprednisolone, started on gabapentin and switched from naproxen to meloxicam. (Tr. 580-81) On the advice of the staff physician, he also requested and was issued a cane. (Tr. 583, 578-79)

         On September 29, 2014, Plaintiff saw Dr. Neela Ramaswamy, M.D., for a pain consult. (Tr. 569) He rated his pain that day as 6 out of 10, and reported that he could neither lie on his back nor bend over.[8] (Tr. 570) Range of motion in all directions was limited due to pain. (Tr. 571) As a result, Dr. Ramaswamy decided to perform a series of epidural steroid injections (“ESIs”). (Tr. 572) The procedures were performed on October 1 and October 15, 2014. (Tr. 562-63, 566-67)

         On October 28, 2014, Plaintiff had a routine follow-up visit, where he reported a pain level of 3 out of 10. (Tr. 558) He also reported his usual pain level as a 4, and when asked what an acceptable level of pain to live with would be, he answered “0”. (Tr. 559)

         On February 3, 2015, Plaintiff was seen by Dr. Ramaswamy for continuing pain in his lower back. (Tr. 982) She noted that previous ESIs had only provided relief for 2-3 weeks. (Id.) Nevertheless, on February 11, 2015, Plaintiff underwent another spinal injection. (Tr. 979-82)

         On April 1, 2015, Plaintiff again saw Dr. Ramaswamy, complaining that the effects of the ESI lasted only two days and that he could hardly function. (Tr. 1374) She referred him for a neurosurgical consult, a back brace and more ESIs. (Id.) The ESIs were performed on April 15 and May 6, 2015. (Tr. 1368-69, 1361) In the latter case, Dr. Ramaswamy placed the injection in the L4 level, because she thought that might be the source of the pain. (Tr. 1361)

         On April 8, 2015, Plaintiff saw Dr. Louis Caragine, M.D. Ph.D., for a neurosurgical consult. (Tr. 1370) Plaintiff reported that the pain in his left buttock and down the back of his thigh was actually worse than the lumbar pain. (Id.) Dr. Caragine noted that Plaintiff had full motor strength in all muscle groups, and was able to lift up his heels and go back on his toes. (Id.) He also noted that Plaintiff had poor flexibility (which he ascribed to the long period since Plaintiff last had physical therapy) and was not able to do a straight-leg raise with his right leg, although he had an 80 degree raise on the left. (Id.) Pending results from an upcoming MRI, Dr. Caragine recommended conservative management including more therapy. (Tr. 1370-71)

         On May 13, 2015, Plaintiff again saw Dr. Caragine. (Tr. 1321) Dr. Caragine expressed some doubts as to Plaintiff's home compliance, stating that he “can tell that [Plaintiff] does not do any significant stretching or any conservative management on his own.” (Tr. 1322) He noted that Plaintiff had significant stiffness and reduced range of motion, and that the disc bulge noted on his previous MRI could be irritating a nerve root. (Id.) Pending the results of a follow-up MRI, Dr. Caragine recommended a course of additional physical therapy. (Tr. 1322-23)

         On May 15, 2015, Plaintiff underwent another MRI on his lumbar spine. (Tr. 1293) It revealed a retrolisthesis (displacement of one vertebra relative to its neighbor) between the L5 and S1 vertebrae, evaluated as the mildest “grade 1” variety. (Id.) The MRI showed multilevel disc desiccation with a mild loss of disc height at ¶ 5-S1, mild bilateral facet hypertrophy and minimal endplate degenerative changes. (Tr. 1294) The interpreting neuroradiologist compared this scan with the September 2013 study, and concluded that it showed “unchanged degenerative changes of lumbar spine with a central disc protrusion at ¶ 5-S1 without significant central canal or neural foraminal stenosis.” (Id.)

         Plaintiff had an initial evaluation at ProRehab's facility in Farmington, Missouri on May 22, 2015. (Tr. 1839) The physical therapist noted that he had a “very limited” range of motion, but that Plaintiff's strength in his key muscle groups was “intact.” ...


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