United States District Court, W.D. Missouri, Western Division
DOLAN R. RICH, JR., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
NANETTE K. LAUGHREY UNITED STATES DISTRICT JUDGE
Dolan R. Rich, Jr. appeals the Commissioner of Social
Security's final decision that he was not under a
“disability” prior to March 28, 2016, but
granting his applications for disability insurance and
supplemental security income benefits under Titles II and XVI
of the Social Security Act as of his fiftieth birthday,
3/28/2016. For the reasons set forth below, the Court affirms
alleges that he became disabled on 1/11/2011 due to severe
mental impairments of generalized anxiety disorder and PTSD,
and severe physical impairments including lumbar and cervical
degenerative disc disease, lumbar dextroscioliosis,
cholelithiasis status post cholecystectomy, hypertension, and
uncontrolled diabetes. He filed his initial applications for
disability insurance and supplemental security income
benefits on 5/9/2012. The ALJ held a hearing on 3/12/2014 and
subsequently issued a partially favorable decision finding
Rich disabled as of the date of his fiftieth birthday,
3/28/2016. Rich appealed the onset date to the Appeals
Counsel, which declined review in a letter dated 6/5/2017.
Rich subsequently appealed to this Court.
disability claim is based primarily on lumbar and cervical
degenerative disc disease, lumbar dextroscioliosis,
cholelithiasis status post cholecystectomy, hypertension,
uncontrolled diabetes, generalized anxiety disorder, and
2011, Rich was diagnosed with Type II diabetes. Tr. 353-54.
Lantus insulin, Metformin, and Vitamin D were prescribed. Tr.
April 2012, Rich saw Randall, FNP. He reported low back pain
due to working with heavy lifting. He experienced tingling in
his feet. He was diagnosed with lumbago and diabetes mellitus
(DM) type II (uncontrolled). Tr. 364. X-rays of the lumbar
spine on 4/20/2012 revealed a transitional vertebra suspected
at ¶ 12, minimal dextroconvex lumbar scoliosis, limbus
vertebra suspected at ¶ 1, and question of
cholelithiasis. Tr. 407. X-rays of the thoracic spine showed
mild levoconvex scoliosis in the thoracic spine and mild
dextroconvex scoliosis in the lumbar spine, as well as
moderate degenerative disc disease, particularly between T6
and T10 with accentuated dorsal kyphosis. Tr. 408. X-rays of
the cervical spine were significant for moderate degenerative
disc disease at ¶ 5-C6 and C6-C7 and suspected prominent
transverse processes at ¶ 7 bilaterally. Tr. 409.
2012, Randall, FNP, examined Rich again. Rich reported
continuous back pain. His blood sugar readings ranged
200-400, and had been as high as 600. Tr. 358. Imaging showed
a suspected gallstone, and he was referred for an ultrasound.
He was referred for diabetes education and to orthopedics for
back pain. Tr. 360. An ultrasound of Rich's abdomen on
5/18/2012 showed cholelithiasis, fatty infiltration of the
liver, and hypoechoic hepatic mass in the margin of the right
hepatic lobe (likely representing a hemangioma). Tr. 406.
the next several months, Rich reported continuous pain in his
chest, abdomen, and back. Tr. 395. Right upper quadrat
abdominal pain was consistent with gallstones, but he wanted
to wait until he had insurance to get his gallbladder
removed. Tr. 396. Tylenol Arthritis was recommended. Tr.
February 2013, Randall, FNP, examined Rich. Rich reported
pain in his neck, hernia pain, headaches, and swelling in his
feet and ankles. Tr. 412. Randall advised him “not to
sit for long periods of time with [his] feet dependent”
and to sleep with his feet elevated; diabetic support hose
were recommended to prevent swelling. Diagnoses included DM
type II (uncontrolled), mixed hyperlipidemia, elevated liver
enzymes, and degeneration of intervertebral disc. Lantus and
Pravastatin were prescribed. Tr. 414.
December 2013, Dr. Bustle examined Rich for diabetes and back
pain. Rich described his low back pain as persistent but
stable; he rated his pain an 8/10. Tr. 418, 422. Dr. Bustle
noted moderate musculoskeletal pain with motion and pain
radiating down Rich's legs with movement. Blood sugars
were running in the low 200s after restarting Lantus. DM type
II (uncontrolled), lumbago, and cervicalgia were diagnosed.
Lantus, Metformin, and Tramadol were prescribed. Tr. 420,
425. An MRI of Rich's lumbar spine on 12/16/13 showed
diffuse hypointense marrow signal intensity. Tr. 429. An MRI
of the cervical spine revealed mild cervical spondylosis
without significant disc abnormality, moderate to severe left
neural foraminal stenosis at ¶ 5-C6, and diffuse
hypointense marrow signal. Tr. 431.
April 2014, Dr. Bustle examined Rich. Rich reported that he
was not able to afford his pain medication but was able to
afford insulin and Metformin. Tr. 470. He rated his pain a
9/10. Tr. 472. Diagnoses included acute sinusitis, DM
(uncontrolled), and hyperlipidemia. An injection of Rocephin
was given, and Amoxicillin was prescribed. Tr. 473.
2014, Dr. Bustle examined Rich again. Rich reported low back
pain and that his feet and legs were numb and sometimes
swollen. Tr. 482. He rated his pain a 9/10. He could not
afford Hydrocodone and was using Tylenol for pain. An exam
confirmed mild pain with motion. Tr. 485. Diagnoses were DM
(uncontrolled) and lumbago. Farxiga, Lantus insulin, and
Metformin were prescribed. Tr. 485.
September 2014, Rich presented to the ED with back pain,
rated an 8/10. An exam revealed tenderness of the right
thoracic and lumbar costovertebral angle. Tr. 514. CT of the
abdomen showed cholelithiasis and non-obstructing left lower
pole renal calculi. Thoracic strain was diagnosed, and
Vicodin was administered. Voltaren, Soma, and Tramadol were
prescribed. Tr. 515. Rich saw Dr. Bustle for follow-up on
9/18/2014, again reporting back pain rated at ¶ 8/10.
His blood sugars ranged 82-200s. Tr. 496, 499. Invokana was
prescribed. Tr. 500. Dr. Bustle examined Rich again on
9/25/2014. Rich reported feeling better on Invokana and that
his blood sugars were running 80-141. He continued to have
chronic low back pain. Tr. 491. Rich was referred to
endocrinology, and Hydrocodone was prescribed. Tr. 494.
November 2014, Dr. Miller examined Rich. Rich was having
numbness over his entire body. Tr. 675. An exam revealed
positive Chvostek's sign bilaterally with light tapping.
Tr. 677. Diagnoses were iatrogenic hypocalcemia and
hypomagnesemia. Magnesium replacement was started, and
calcium replacement was increased. Tr. 678.
January 2015, Dr. Bustle examined Rich based on reported pain
in his back, knees, and feet. Tr. 739. Hydrocodone was
prescribed. Tr. 740.
April 2015, Dr. Bustle examined Rich for reported back pain,
chest discomfort, and abdominal pain in the upper right
quadrant. Tr. 726. Rich rated his pain a 9/10. An exam
revealed lumbar pain with motion. Tr. 730. Hydrocodone was
refilled. Tr. 731. A hepatobiliary scan on 4/20/2015 showed
no evidence of acute cholecystitis. Tr. 723. Ultrasound of
the abdomen showed cholelithiasis without biliary ductal
dilation. Tr. 724.
2015, Rich saw Dr. Joyce for gallbladder issues. He reported
right upper quadrant abdominal pain that radiated to the
epigastric area and right chest, and occasional attacks of
severe abdominal pain. Tr. 771. He rated his pain a 10/10.
Tr. 775. Diagnoses included symptomatic cholelithiasis. Tr.
2015, Rich presented to the ED with back pain in the
bilateral thoracic area. He reported symptoms worse with
movement, twisting and walking. Tenderness was noted in the
right thoracic and midline thoracic areas. Tr. 787. X-rays of
the thoracic spine showed thoracic spondylosis. Tr. 784 -85.
Morphine and Phenergan were administered; Percocet was
prescribed. Tr. 790. Dr. Bustle conducted a follow-up
examination, during which Rich reported worsening back pain.
He had not filled his ED prescription for Percocet due to
finances. Tr. 761. An exam revealed thoracic spine tenderness
and moderate lumbar spine pain with motion. Tr. 764.
Diagnoses included lumbar radiculitis, thoracic spine pain,
and constipation. Hydrocodone and Colace were prescribed. Tr.
of Rich's thoracic spine on 7/6/2015 revealed thoracic
scoliosis and spondylosis, epidural lipomatosis posterior and
to the left of the cord, which created deformity of the cord
throughout the upper and mid aspect of the thoracic ...