United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
W. SIPPEL, UNITED STATES DISTRICT JUDGE.
Mikel Hays brings this action pursuant to 42 U.S.C.
§§ 405(g) seeking judicial review of the
Commissioner's decision denying his application for
disability insurance benefits and supplemental security
income under Titles II and XVI of the Social Security Act, 42
U.S.C. §§ 1381 et seq. Because the
Commissioner's final decision is supported by substantial
evidence on the record as a whole, I will affirm the decision
of the Commissioner.
Mikel Hays asserts that he is disabled based on his lower
back and leg pain, hypertension, anxiety, and his
post-traumatic stress disorder (PTSD). His back injury
originates from a fall on the ice. His PTSD originates from
Hays' witnessing a friend shoot himself while they were
in the military.
October 19, 2011, Hays saw Dr. Jerry Meyers at the
Breakthrough Pain Relief Clinic. Hays reported that he had
low back pain and a history of a herniated pulposus at ¶
5-S1. The diagnosis was chronic back pain and herniated
nucleus pulposus L5-S1 by history. Dr. Meyers proscribed
Percocet and Valium.
December 28, 2011, Hays was seen by Dr. Meyers regarding his
back pain. Hays had recurrent symptoms secondary to operating
a Bobcat and lifting, Hays was doing concrete and roofing
December 26, 2013, Hays was seen by Dr. Meyers who indicated
that Hays had recurrent back pain. Hays was able to flex to
60° extend 15° and rotate left and had positive lower
extremity symptoms. Percocet and Flexeril were prescribed.
August through November 2014, Hays was an inmate in the St.
Charles County Department of Corrections. He reported lower
back pain radiating to hips and legs. Hays' had an
initial psychiatric evaluation in the jail on September 12,
2014. Hays reported that he had been subjected to physical
and emotional abuse and at age 2 had a broken jaw. He
reported that did not do well in confined spaces, had
nightmares about people raping him, and that another soldier
had shot himself. His mood and affect were depressed and
anxious but he was fully oriented to place, had fair insight,
and good to fair judgment. Hays was diagnosed with anxiety
disorder, depression, and PTSD and prescribed Buspar. While
Hays was in jail he was approved for inmate work status.
Hays' initial counseling intake form, dated September 9,
2014, notes that Hay's had been diagnosed with PTSD after
seeing a friend kill himself in the 1980s. He was tearful and
sobbing during the exam and was counseled regarding coping
skills but Hays was scarcely interested in the
counselor's attempts to discuss coping strategies. In
October 2014, he was prescribed Paxil and Clonidine.
December 3, 2014, Hays went to St. Anthony's Medical
Center's ER with complaints of back pain indicating he
had run out of Percocet and Valium the prior day. He was
diagnosed with chronic back pain and hypertension. He was
prescribed hydrochlorothiazide (HCTZ) for his high blood
March 2, 2015, Hays presented himself to the emergency room
at Mercy Hospital in St. Louis. He complained of chronic back
pain and reported that he had stopped taking his pain
medications the prior week. He reported that his lower back
pain had become exacerbated on August 7, 2014 and had
progressively gotten worse. He stated that he injured his
L5-S1 vertebrae in 1997 when he had slipped and fell on the
ice. He described his pain as a 10 on a scale of 10. An
examination revealed lower back pain with no gait problems,
no neck pain or neck stiffness. The exam was also negative
for any neurological or psychiatric problems. Hays had a
normal range of motion of the back with tenderness, no edema,
tenderness to L3L4, amd straight leg raising being negative
bilaterally. The diagnosis included degenerative disc
disease, arthritis, stain or sprain.
7, 2015, Hays filled out a function report in support of his
social security disability claim. In that report Hays claimed
that he used a back brace only sometimes if he could not stop
or lay down to ease lower back pain. He reported that generic
valium gave him bad headaches. He stated that he could not
stand to be around large crowds or loud noises. Hays
indicated that he could not sit or stand for more than 15-30
minutes; no driving of a light vehicle or heavy equipment;
and he does not sleep more than 1 to 2 hours per night. He
reported that his days are spent sitting and walking but
mostly laying around to try to ease the pain in his lower
back. He could prepare small meals once or twice a day and
does housework including doing dishes but his mother and
girlfriend do his laundry. He does not do household repairs
or mowing. He gets out of the house everyday and can drive or
ride in a car but not for longer than 15-30 minutes. He can
shop for himself for food, clothes, and personal hygiene
items but makes a list so he can get what he needs and get
out in 5 to 15 minutes. Hays reports he can talk with family
and friends and reiterated he “can't stand”
to be around crowds. He asserts that he cannot lift more than
5 pounds due to his back pain. He can only walk 50 to 100
feet before having to rest. He can only pay attention for
5-10 minutes, has a problem following anything, and does not
get along with authority figures because of his PTSD. He
indicated that his condition affects his ability to lift,
squat, bend, stand, reach, walk, sit, kneel, talk, climb
stairs, concentrate, complete tasks, his memory, his ability
to follow instructions, the use of his hands, and getting
along with others. Hays reported that he does not handle
stress and is short tempered. His ability to handle a change
in routine is “so-so.” He is able to pay bills,
handle a savings account, count change, and use a checkbook.
August 14, 2015, state agency psychologist James Morgan Ph.D.
reviewed the evidence in Hays' file in connection with
his disability application. He concluded that Hays had a
severe impairment of hypertension and non-severe affective
and anxiety disorders. The affective and anxiety disorders
did not result in any restrictions in the activities of daily
living; created mild restrictions in maintaining social
functioning; mild restrictions in maintaining concentration,
persistence, and pace; with no repeated episodes of
decomposition. Morgan found Hays' statements regarding
his condition to be partially credible because they were
partially supported by the totality of the findings in the
file. He noted that Hays had a limited treatment history and
did not currently receive any formal mental health attention.
Given Hays' lack of treatment and his most recent mental
status, Morgan concluded that Hays' mental impairment was
October 26, 2015, Hays presented himself for the first time
to the Pacific Primary Clinic. He reported to Dr. Heather
Gjorgjievski, OD that he had lower back pain. Hays stated
that the most discomfort was in his lower left and right
lumbar spine with pain radiating to his legs. He said this
condition was intermittent, moderate in intensity. He
reported that this was a chronic problem with essentially
constant pain which began more than 15 years ago when he fell
on ice while he was at work. He stated that he saw a
micronuerologist who advised against surgery. Hays told Dr.
Gjorgjievski that he stopped seeing a pain management doctor
2 years ago but has seen different urgent care doctors. He
also told Dr. Gjorgjievski that he had PTSD beginning 29
years ago that is of moderate intensity. He estimated that he
experienced symptoms several times a day but that the
duration of an episode was quite variable. Aggravating
factors included crowds. An associated symptom was insomnia.
He reported that his symptoms were relieved with medication.
His hypertension was discovered a year ago by a jail doctor.
He controls his hypertension with diuretic HCTZ and
lisinopril. He takes his medication regularly and had no
associated symptoms. He has smoked cigarettes for 30 years
and is down to smoking one pack a day from three packs a day.
An examination revealed normal results including blood
pressure, cardiovascular functions, and psychiatric state.
The diagnosis was low back pain, PTSD, hypertension,
cigarette smoking. Hays was prescribed the antidepressant
venlafaxine, clonidine for hypertension, a refill of the
muscle relaxant cyclobenzaprine, oxycodone/acetaminophen for
pain, a refill of the diuretic HCTZ, a refill of lisinopril
for high blood pressure, and meloxicam a nonsteroidal
November 23, 2015, Hays had a follow-up visit with Dr.
Gjorgjievski and had his prescriptions refilled. On December
21, 2015, Hays was seen by Dr. Gjor for a follow-up visit. He
reported being able to go out to lunch with his mom and dad
even though he had to leave halfway through but saying that
was an improvement due to his difficulty in dealing with
crowds. His prescriptions were refilled. On January 19, 2016,
Hays had a follow-up visit with Dr. Gjorgjievski for lower
back pain and PTSD. His prescriptions were refilled. On
February 17, 2016, Hays attended a follow-up visit with Dr.
Gjorgjievski for hypertension, low back pain, and insomnia.
His mood was stable and he was feeling good psychiatrically.
His prescriptions were refilled. On March 11, 2016, Hays had
a follow-up appointment with Dr. Gjorgjievski for his PTSD
which was of moderate intensity. He was now going to the
stores late at night which he had not been able to do before.
He had insomnia and was having some bad dreams but he was not
always on edge anymore. He complained of lower back pain. His
prescriptions were refilled.
continued to have follow-up appointments with Dr.
Gjorgjievski from April 15, 2016 through January 10, 2018.
Each time Hays complained of back pain and sometimes pain in
his legs. His anxiety symptoms were much the same as in past
visits. In addition to his normal prescriptions being
refilled he was prescribed Xanax and Lamictal in early 2017
which helped his anxiety and anger issues. On February 1,
2018, Dr. Gjorgjievski wrote a letter stating that Hays does
not work secondary to chronic pain and PTSD with agoraphobia.
She states that Hays is dependent on his mother for financial
support, food, clothing, shelter, transportation, and all
medical expenses for 2016.
February 19, 2015, Hayes filed a Title II application for a
period of disability and disability insurance benefits. He
also protectively filed a Title XVI application for
supplemental security income on the same date. He alleged
that his disability began on September 1, 1995. On August 17,
2015, the agency denied Hays' claims. Hays requested a
hearing before an Administrative Law Judge (ALJ) to challenge
the denial of his claims. On April 18, 2017, Hays,
accompanied by counsel, attended the hearing before the ALJ.
On October 18, 2017, the ALJ issued her decision finding that
Hays was not under a disability. On June 26, 2018, the
Appeals Council denied Hays' request for review.
hearing before the ALJ, Hays testified that he was 48 years
old, a high school graduate, and lived with his mother. Hays
had worked intermittently in the past as a general contractor
and auto mechanic. He trained in the military as a chef.
testified that his medical conditions kept him from being
able to work. He said he bursts out crying or in anger for no
reason. Walking on concrete caused him severe pain in his
lower back, hips, and knees. Sitting too long and standing
too long hurt his back. Too long sitting would be 30 to 35
minutes. He would then need to walk around or lay down to
ease his lower back pain. Standing too long would be 15 to 30
minutes. He would need to sit down or lay down. He asserts
that he spends 40 percent of his day laying down.
testified that it causes him severe pain to walk more than 50
yards. When he mows the grass he has to get off the mower
every 15 minutes to lay down and ease his back pain. When
asked about his anger issues, Hays related a story where he
hit a fellow inmate in jail in 2014 because the inmate kept
saying that the inmate was in a minority. He testified that
on a daily basis he can get angry to the point where he yells
and screams and throws things. The sort of things that set
him off are crowds and hearing people complain about
anything. So it is hard for him to go to restaurants. When he
goes with his family to a restaurant he has get up and go
outside several times to relieve his mood and ultimately has
to leave. He does not like strangers to sit behind him or to
the right and left of him because the noise makes him feel
trapped. He feels threatened around strangers but not around
family. When he feels nervous he concentrates on what makes