Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Taylor v. Berryhill

United States District Court, W.D. Virginia, Abingdon Division

February 21, 2018

LARRY KERMIT TAYLOR, Plaintiff
v.
NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant

          MEMORANDUM OPINION

          Pamela Meade Sargent United States Magistrate Judge.

         I. Background and Standard of Review

         Plaintiff, Larry Kermit Taylor, (“Taylor”), filed this action challenging the final decision of the Commissioner of Social Security, (“Commissioner”), determining that he was not eligible for disability insurance benefits, (“DIB”), under the Social Security Act, as amended, (“Act”), 42 U.S.C.A. § 423 (West 2011), following a redetermination hearing, held pursuant to 42 U.S.C. § 405(u). Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g). This case is before the undersigned magistrate judge upon transfer pursuant to the consent of the parties under 28 U.S.C. § 636(c)(1).

         In Counts I through VII of his Complaint, Taylor challenges the legality of the procedure used to redetermine his eligibility for DIB benefits pursuant to 42 U.S.C. § 405(u). In these counts, Taylor argues that the redetermination procedure violated his due process rights under the Fifth Amendment, the Administrative Procedures Act, the Social Security Act and the Social Security regulations. He also argues that the redetermination did not occur “immediately” as required by 42 U.S.C. § 405(u). In Count VIII of his Complaint, Taylor argues that the Commissioner's decision that he was not disabled was not supported by substantial evidence.

         The record shows that Taylor filed an application for DIB on July 1, 2010, alleging disability as of June 23, 2010. (Record, (“R.”), at 263-66.) He hired Eric C. Conn, a then-prominent Social Security practitioner in the region, as his attorney. When Taylor's claim was initially denied on August 18, 2010, he sought reconsideration. (R. at 115-26.) Thereafter, on October 20, 2010, Taylor's request for reconsideration also was denied. (R. at 127-29.) Taylor then requested a hearing before an Administrative Law Judge, (“ALJ”). (R. at 134.) On January 7, 2011, Taylor underwent a consultative examination by Dr. Srini Ammisetty, M.D., arranged by Conn. (R. at 525-27.) Taylor was awarded DIB benefits by decision dated February 2, 2011, by ALJ David B. Daugherty and entered without a hearing. (R. at 9, 106-09.) ALJ Daugherty's favorable decision was based, in part, on the examination and report of Dr. Ammisetty.

         On May 12, 2015, the Social Security Administration's, (“SSA” or “Agency”), Office of the Inspector General, (“OIG”), informed SSA that it had reason to believe fraud was involved in applications for benefits for approximately 1, 800 individuals, including Taylor, whose cases involved evidence from Bradley Adkins, Ph.D., Dr. Srini Ammisetty, M.D., Dr. Frederic Huffnagle, M.D., or Dr. David P. Herr, D.O., dated between January 2007 and May 2011. (R. at 337.) More specifically, OIG had reason to believe that Conn, or his law firm, submitted precompleted “template” residual functional capacity forms, some of which were from Dr. Ammisetty, between January 2007 and May 2011, in support of these individuals' applications for benefits. On May 18, 2015, the Appeals Council informed Taylor it was redetermining the decision granting him DIB benefits on or before February 2, 2011. (R. at 153-56.) The Appeals Council further notified Taylor that the OIG directed it to disregard any evidence from Dr. Ammisetty when that information was submitted by Conn or representatives associated with his law firm. (R. at 153.) The Appeals Council explained that Dr. Ammisetty had provided evidence in his case that ALJ Daugherty used to find him disabled, and the ALJ relied solely on Dr. Ammisetty's medical source statement and did not evaluate any other evidence or medical opinions. (R. at 154.) Without considering Dr. Ammisetty's residual functional capacity form, the Appeals Council concluded that there was not sufficient evidence in the file to show that Taylor was disabled on or before February 2, 2011, the date Taylor previously had been awarded benefits. (R. at 154-55.) The Appeals Council invited Taylor to submit additional evidence or statements and granted his request for an extension of time within which to do so. (R. at 155, 159.) Taylor did submit additional medical evidence in June 2015.

         In August 2015, after reviewing the additional evidence or statements supplied by Taylor, the Appeals Council set aside the prior favorable decision and remanded Taylor's case to a different ALJ for further action and a new decision. (R. at 111-14.) The Appeals Council gave Taylor an opportunity for a hearing before another ALJ, ALJ Gavras, and an opportunity to testify and submit evidence that was new, material and related to the period at issue. Taylor elected to appear and testify at the April 2016 hearing with the assistance of counsel. (R. at 30-74.) As a result of that redetermination hearing, ALJ Gavras, by decision dated April 21, 2016, found there was insufficient evidence to support Taylor's entitlement to DIB benefits at the time he was originally awarded them. (R. at 12-16.)

         The ALJ found that Taylor met the insured status requirement of the Act for DIB purposes through December 31, 2011. (R. at 12.) The ALJ also found that Taylor had not engaged in substantial gainful activity during the period from his alleged onset date of June 23, 2010, through February 2, 2011, the date Taylor previously was awarded benefits.[2] (R. at 13.) The ALJ found that the medical evidence established that Taylor suffered from the following medically determinable impairments during the relevant period: hypertension; hyperlipidemia; and fatty liver infiltration, but he found that Taylor did not have a severe impairment or combination of impairments. (R. at 13.) Thus, the ALJ found that Taylor was not under a disability as defined under the Act from June 23, 2010, through February 2, 2011, and was not eligible for benefits. (R. at 16.) See 20 C.F.R. § 404.1520(c) (2017). That being the case, the ALJ terminated Taylor's benefits and notified him that SSA may treat any benefits previously received as overpayments, but that he could request that any such overpayment be waived. (R. at 16.) Upon Taylor's request, the Agency waived the $116, 167.70 overpayment in DIB benefits that Taylor had received.

         Taylor requested review of the ALJ's decision, (R. at 5), which the Appeals Council denied on September 7, 2016. (R. at 1-3.) Taylor then filed the present action on November 3, 2016, to appeal the Commissioner's unfavorable redetermination decision, which now stands as the Commissioner's final decision. See 20 C.F.R. § 404.981 (2017). He challenges not only the merits of the Agency's decision, but also raises challenges to the redetermination procedure as set out in the Act. This case is before the court on Taylor's motion for summary judgment filed May 4, 2017, and the Commissioner's motion for summary judgment filed June 19, 2017.

         On June 1, 2015, during the pendency of Taylor's redetermination, he filed new claims for DIB and SSI. Although, typically, a claimant can have only one active claim at a time, the Commissioner is allowing former clients of Conn to file new claims during the redetermination of their old claims because the two claims generally cover different time periods. The redetermination is limited to the period that was previously awarded, while the new claims cover the period afterwards. On October 14, 2016, the SSA denied Taylor's DIB claim, finding that his date last insured was December 31, 2012, [3] and his treatment records did not show disability as of that date. (Docket Item No. 17-2.) However, on October 28, 2016, the Agency awarded Taylor's SSI claim because it found him disabled as of June 1, 2015. (Docket Item No. 17-3.) He currently is receiving SSI benefits in the amount of $191.31 per month. Taylor is seeking review before the Agency of the denial of DIB benefits.

         II. Facts[4]

         The court finds it necessary to include a description of the unusual circumstances leading up to the redetermination of Taylor's prior DIB award. The record shows that the government indicted Conn, ALJ Daugherty and Dr. Bradley Adkins in an 18-count indictment returned on April 1, 2016. Dr. Ammisetty was not indicted. See United States v. Conn, et al., No. 5:16-cr-22 (E.D. Ky. Apr. 1, 2016). (Docket Item No. 17-5.) On March 24, 2017, Conn pled guilty in federal court to his role in a scheme to defraud the Agency. See United States v. Conn, No. 5:17-cr-43 (E.D. Ky. Mar. 24, 2017). (Docket Item No. 17-6.) Conn agreed to a factual basis to support his plea, including that he submitted the falsified medical documents, and former SSA ALJ Daugherty authored decisions granting disability benefits in nearly 1, 800 claimants' cases. (Docket Item No. 17-7.) Conn admitted he paid medical professionals to sign medical forms that he fabricated before evaluations of claimants occurred. According to his guilty plea, Conn routinely prepared, and medical professionals signed, evaluation reports indicating that claimants had limitations considered disabling by the SSA, irrespective of the claimants' actual physical or mental conditions. On or about June 2, 2017, Conn removed his electronic monitoring device while under house arrest and fled his home, about a month before his scheduled July 2017 sentencing. See www.kentucky.com/news/state/article156523654.html (last visited Feb. 15, 2018). In July 2017, Conn was sentenced in absentia to 12 years in prison. Law enforcement apprehended him on December 2, 2017, in Honduras. The original 18-count indictment against Conn remains in effect, and the government intends to prosecute him pursuant to it, in addition to escape and related charges. See www.kentucky.com/news/state/article189653509.html (last visited Feb. 15, 2018).

         Taylor was born in 1955, which classified him as a “person of advanced age” under 20 C.F.R. § 404.1563(e) during the relevant time period. (R. at 39.) He has a ninth-grade education and past relevant work experience as a truck driver. (R. at 40-41.)

         At his April 2016 hearing, Taylor testified that he last worked as a coal truck driver in 2010. (R. at 42-43.) He stated that he quit working because he “couldn't do [his] job to satisfy the people that [he] was working for.” (R. at 43.) He stated that he had to stop and walk around for 15 or 20 minutes every two or three hours due to back pain and leg numbness and pain. (R. at 43-44, 58.) Taylor testified that he broke his tailbone and was off work for about two months, after which time he had experienced low back pain. (R. at 45.) He stated that he could not afford to go to the doctor, and he explained that is why he did not take pain medications and why there are not many medical records in his file relating to the relevant time period. (R. at 45-46.) Nonetheless, Taylor stated that he went to the doctor a few times, but they could not determine the cause of his problems. (R. at 45.) He said that, prior to 2011, he was told he had a few deteriorated discs, a “spot” on his liver and a lot of stomach problems, carpal tunnel syndrome in both wrists and fingers, which caused numbness, and high blood pressure, which was controlled fairly well with medications. (R. at 46, 51, 58-59.) Taylor stated that he did only what he had to do at home, including mowing the yard if there was no one else to do it. (R. at 46-47.) He stated that he could stand for 30 to 45 minutes without experiencing back pain. (R. at 47.) Taylor stated that he would lie down on the couch a lot in an effort to relieve his pain. (R. at 48.) He stated that he could drive if he had to. (R. at 49.)

         Taylor also testified that he experienced mood swings, depression, anxiety and nervousness, but he did not seek any mental health treatment because he could not afford it. (R. at 59.) He also stated that he never had to seek emergent treatment for such mental health issues. (R. at 59.)

         Taylor's daughter, Kayla Taylor, also testified at this hearing. (R. at 61-63.) She stated that she was 18 years old in 2010 and lived with her father. (R. at 62.) Kayla Taylor stated that her father was in a lot of pain all the time, and he could not work as long of hours as he had previously. (R. at 62.) She stated that he complained of pain in his back, legs, arms and feet daily. (R. at 63.) Kayla Taylor stated that when Taylor was home, he would alternate among the couch, the recliner and the bed. (R. at 62.) She testified that Taylor had to rest all weekend in order to be able to work the following week. (R. at 62.) Kayla Taylor stated that her father did not participate in any of her school-related activities. (R. at 62-63.)

         Theresa Wolford, a vocational expert, also was present and testified at Taylor's hearing. (R. at 66-71.) Wolford classified Taylor's past work as a tractor trailer truck driver as medium[5] and semi-skilled work. (R. at 66.) Wolford testified that an individual who could perform simple, routine medium work would not be able to perform Taylor's past relevant work as a truck driver. (R. at 66-67.) However, she testified that such an individual could perform other jobs existing in significant numbers in the national economy, including those of a hand packager and a laundry worker. (R. at 67.) Wolford testified that a hypothetical individual who could perform the full range of light[6] work also could not perform Taylor's past work as a truck driver. (R. at 67-68.) Wolford testified that an individual who could perform simple, routine medium work, but who could sit for only two hours at a time, could perform the jobs previously enumerated. (R. at 68-69.) Likewise, she testified that if that individual could stand for only two hours at a time, he still could perform those jobs. (R. at 69.) Wolford testified that with unskilled work, typically, employers will tolerate being off task approximately 15 percent of the time in addition to regularly scheduled breaks. (R. at 70.) She further testified that employers typically tolerate one to two absences monthly at the unskilled level of work, noting that if the employee would need two absences on a monthly, continuous basis, he would have difficulty maintaining competitive employment. (R. at 70.)

         In rendering his decision, the ALJ reviewed medical records from Family Care Center; Clinch Valley Medical Center; Buchanan General Hospital; Dr. J.N. Patel, M.D.; Pikeville Medical Center; University of Virginia Digestive Health Clinic; Dr. Bert Spetzler, M.D., a state agency physician; and Dr. Joseph Duckwall, M.D., a state agency physician.

         The record shows that Taylor received treatment at Family Care Center[7]from October 2008 through October 2015. On July 13, 2010, Taylor complained of elevated blood pressure, but he reported that he had stopped taking his medication. (R. at 357.) On physical examination, Taylor's blood pressure was 150/100, and he was alert and oriented with an appropriate affect. (R. at 357.) A physical examination was largely normal. (R. at 357.) Taylor could stand erect with a steady gait, despite a reported history of chronic back pain. (R. at 357.) However, Taylor stated that he was quitting his job because he could not stand the pain in his back. (R. at 357.) He was diagnosed with hypertension and a history of increased hyperlipidemia. (R. at 357.) On August 10, 2010, Taylor's blood pressure was 132/78. (R. at 371.) His abdomen was distended, but nontender, and the remainder of his examination was within normal limits. (R. at 371.) Taylor was diagnosed with hypertension, hyperlipidemia and elevated liver function tests. (R. at 371.) A liver ultrasound was ordered, and Taylor was advised to consume no alcohol. (R. at 371.)

         Dr. Bert Spetzler, M.D., a state agency physician, completed an assessment in connection with Taylor's initial disability claim on August 6 and 9, 2010. (R. at 88-93.) After reviewing Taylor's medical records, Dr. Spetzler concluded that he did not suffer from any severe impairments. (R. at 90.) Dr. Spetzler found that Taylor could perform his past relevant work as a truck driver. (R. at 92.) Dr. Spetzler specifically found that Taylor was receiving treatment for high blood pressure and high cholesterol, but neither of these conditions would prevent him from performing normal work activities. (R. at 92-93.) He further found that, although Taylor alleged back pain and pain and numbness in the legs, feet, arms and hands, there was no evidence of significant muscle weakness or nerve damage that would prevent him from working. (R. at 93.) Dr. Spetzler also found that, despite allegations of stomach problems, there was no evidence to indicate that Taylor had received treatment for this condition. (R. at 93.) Finally, Dr. Spetzler noted that, although Taylor was concerned about mood swings, depression and anxiety, the evidence did not indicate that he had ever received treatment for such conditions or that they would significantly affect his ability to remember, understand or communicate with others. (R. at 93.) Dr. Spetzler concluded that Taylor's condition did not result in significant limitations in his ability to perform basic work activities. (R. at 93.) Thus, he found that Taylor's condition was not disabling. (R. at 93.)

         On August 19, 2010, an ultrasound of Taylor's liver revealed a small echo-poor mass in the right lobe, probably representing a hemangioma. (R. at 382-83.) It also revealed another larger echo-poor mass in the midline measuring roughly 5 x 6 centimeters, representing a mass probably arising from the pancreas or, less likely, the liver. (R. at 382.) A CT scan was recommended for further evaluation. (R. at 382.) This CT scan of Taylor's abdomen and pelvis was performed on August 30, 2010, and revealed low attenuation of the liver compatible with diffuse fatty liver infiltration. (R. at 381.) There also were multiple hepatic masses, the largest of which was 8 centimeters in diameter and located in the left lobe. (R. at 381.) The appearance was most suggestive of multiple hemangiomata, but other possible etiologies included metastatic disease, multifocal hepatoma, focal nodular hyperplasia or adenomas, and an MRI was recommended for further confirmation. (R. at 381.)

         On September 24, 2010, Taylor was seen at the University of Virginia Digestive Health Clinic for evaluation of liver lesions. (R. at 376-79.) Dr. Anshu Mahajan, M.D., reviewed the results of Taylor's diagnostic studies. (R. at 376.) Taylor's blood pressure was 129/69, and he was alert and oriented and in no acute distress. (R. at 377.) Taylor's abdomen was soft, nontender and nondistended with present bowel sounds. (R. at 377.) The liver edge was palpable. (R. at 377.) There was no clubbing, cyanosis or edema of the extremities. (R. at 377.) Dr. Mahajan concluded that Taylor's abnormal liver function tests were likely due to fatty liver. (R. at 377.) He opined that the masses on the CT scan probably represented hemangiomas, but their size was concerning. (R. at 377.) Dr. Mahajan stated that Taylor's case would be discussed at the Interdisciplinary Hepatology Tumor Board. (R. at 377.) He ordered lab work in anticipation of a possible liver biopsy. (R. at 377.) For Taylor's fatty liver, Dr. Mahajan recommended exercise, diet and alcohol abstinence. (R. at 377.) After discussing Taylor's diagnostic studies with the Interdisciplinary Hepatology Tumor Board, it was recommended that Taylor follow up with either a tagged red blood cell scan or another three-phase contrast CT scan in six months to evaluate for interval change or increase in size. (R. at 378.)

         On October 14 and 18, 2010, Dr. Joseph Duckwall, M.D., a state agency physician, completed an assessment in connection with the reconsideration of Taylor's claims. (R. at 94-100.) After reviewing the medical evidence of record, Dr. Duckwall found that Taylor did not suffer from any severe impairments and that he could perform his past relevant work as a truck driver. (R. at 97-99.) Dr. Duckwall further found that Taylor was receiving treatment for high blood pressure and high cholesterol, but neither of these conditions would prevent him from doing normal work activities. (R. at 99.) He further found that, despite Taylor's allegations of back pain and pain and numbness in the legs, feet, arms and hands, there was no evidence that he had significant muscle weakness or nerve damage that would prevent him from working. (R. at 99.) Dr. Duckwall also found that, despite allegations of stomach problems, there was no evidence to indicate that Taylor had received any treatment for such condition. (R. at 99.) With regard to his alleged mood swings, depression and anxiety, Dr. Duckwall noted that the evidence did not indicate that he had ever received treatment for such conditions or that they would significantly affect his ability to remember, understand or communicate with others. (R. at 99.) Dr. Duckwall concluded that Taylor's condition did not result in significant limitations in his ability to perform basic work activities and, therefore, was not severe enough to be considered disabling. (R. at 99.)

         Taylor returned to Family Care Center on November 10, 2010, for medication refills. (R. at 439.) Physical examination at that time was within normal limits. (R. at 439.) Taylor was diagnosed with hyperlipidemia, hypertension, gastroesophageal reflux disease, (“GERD”), and low back pain, and he was continued on medications. (R. at 439.)

         This is the entirety of the medical evidence from the time period relevant to the ALJ's redetermination decision. Taylor explains that there is a dearth of evidence during the relevant time period because he could not afford health insurance. However, once he received DIB benefits, he could afford it, and he began receiving medical treatment more regularly. The evidence that follows is dated subsequent to the February 2, 2011, decision granting Taylor DIB benefits. The ALJ reviewed this evidence, but concluded that it did not relate to the time period relevant to the redetermination. Thus, this court also will consider this evidence in determining whether the ALJ's decision is supported by substantial evidence. See Wilkins v. Sec'y of Dep't of Health & Human Servs., 953 F.2d 93, 96 (4th Cir. 1991).

         On March 28, 2011, Taylor returned to Family Care Center. (R. at 437.) His blood pressure was 122/80. (R. at 437.) He was ambulatory with a steady gait, and he had no complaints of leg or muscle pain. (R. at 437.) Taylor was diagnosed with an upper respiratory infection, hypertension, GERD and hyperlipidemia, and he was prescribed antibiotics. (R. at 437.) In May 2011, Taylor had complaints of congestion, shortness of breath and a cough. (R. at 436.) His blood pressure was 112/70. (R. at 436.) A physical examination was normal, except for nasal congestion. (R. at 436.) Taylor had a full range of motion of the extremities, and he had normal reflexes. (R. at 436.) He was diagnosed with an upper respiratory infection and received antibiotics. (R. at 436.) On October 3, 2011, Taylor had no extremity edema, and his spine and gait were normal. (R. at 435.) He was diagnosed with hypertension and hyperlipidemia, and he was advised to continue his medications. (R. at 435.) On February 20, 2012, Taylor complained of head congestion, cough and GERD. (R. at 434.) He exhibited no extremity edema, and his spine and gait were, again, within normal limits. (R. at 434.) Taylor was diagnosed with hypertension, hyperlipidemia, GERD and an upper respiratory infection, and he received antibiotics. (R. at 434.) On July 11, 2012, Taylor complained of bilateral knee swelling, hypertension, GERD and arthralgias. (R. at 433.) His blood pressure was 130/84. (R. at 433.) On physical examination, Taylor had decreased range of motion in his knees, but his spine and gait were within normal limits. (R. at 433.) He was diagnosed with hypertension, hyperlipidemia, GERD and bilateral knee pain, and x-rays of the knees were ordered. (R. at 433.) On May 10, 2013, Taylor complained of lower back pain with a burning sensation radiating into both legs and feet. (R. at 432.) He also complained of hypertension and myalgias/arthralgias. (R. at 432.) His blood pressure was 140/94, but Taylor stated that he had been out of his blood pressure medication for two days. (R. at 432.) He had a full range of motion of the extremities with no edema, normal reflexes and a steady gait. (R. at 432.) Taylor was diagnosed with hypertension, neuropathy and back pain, and x-rays of the lumbar spine were ordered. (R. at 432.) Taylor was prescribed Neurontin. (R. at 432.)

         X-rays of Taylor's lumbar spine, taken on June 18, 2013, showed levoscoliosis with degenerative disc and joint disease. (R. at 451.) X-rays of Taylor's left foot, taken on November 19, 2014, showed severe arthritic changes at the medial malleolus and mild midfoot arthritic changes, but no definite acute bony abnormalities. (R. at 450.)

         On July 2, 2013, Taylor returned to Family Care Center, complaining that Neurontin was not helping. (R. at 431.) He continued to complain of myalgias/arthralgias, and his blood pressure was 128/72. (R. at 431.) He had a full range of motion of the extremities with no edema and a steady gait. (R. at 431.) However, Taylor exhibited paraspinal muscle tenderness and pain and burning, which radiated into the bilateral lower extremities. (R. at 431.) Taylor was diagnosed with lower back pain, neuropathy in both lower extremities and polyarthropathy. (R. at 431.) He was prescribed Ultram, and his Neurontin dosage was increased. (R. at 431.) On August 21, 2013, Taylor's blood pressure was 107/62. (R. at 430.) He had a full range of motion and no edema of the extremities, and no gross neurological deficits were noted. (R. at 430.) Taylor was diagnosed with allergic rhinitis, an upper respiratory infection, hypertension and hyperlipidemia. (R. at 430.) On November 25, 2013, Taylor complained of bilateral leg pain. (R. at 429.) His blood pressure was 130/90. (R. at 429.) It was noted that Taylor had chronic low back pain, which radiated into both lower extremities with burning and numbness. (R. at 429.) It also was noted that Taylor was limping. (R. at 429.) He was diagnosed with bilateral lower extremity pain and neuropathy. (R. at 429.) On February 26, 2014, Taylor's blood pressure was 140/98. (R. at 427.) He had a full range of motion of the extremities without edema, reflexes were normal, and no neurological deficits were noted. (R. at 427.) He was diagnosed with bronchitis, an upper respiratory infection and congestion. (R. at 427.) On March 22, 2014, a physical examination yielded normal findings. (R. at 423.) Taylor was diagnosed with neuropathy, hypertension, GERD and hyperlipidemia. (R. at 423.) On November 11, 2014, Taylor complained of left foot pain. (R. at 422.) His blood pressure was 140/90. (R. at 422.) A physical examination revealed a full range of motion of the extremities with no edema and normal reflexes. (R. at 422.) Taylor was diagnosed with polyarthropathy, bilateral knee pain, a left foot injury, left foot pain, low back pain, hypertension and neuropathy. (R. at 422.) A left foot x-ray was ordered. (R. at 422.)

         On January 28, 2015, Taylor returned to Family Care Center. (R. at 421.) His blood pressure was 128/82. (R. at 421.) He was diagnosed with peripheral vascular disease, bilateral lower extremity pain, osteoarthritis, polyarthralgia and right knee pain. (R. at 421.) On February 10, 2015, bilateral ankle brachial indices were normal, and dedicated arterial imaging was recommended if symptoms were severe. (R. at 443.)

         On February 13, 2015, Taylor saw Dr. J.N. Patel, M.D., for a consult for a colonoscopy. (R. at 391-93, 409-11.) He complained of left lower quadrant pain for the previous three months, as well as constipation. (R. at 391, 409.) He described the pain as dull, aching and nonradiating, with no aggravating or relieving factors. (R. at 391, 409.) Taylor reported arthritis, back pain, joint pain and stiffness, but he denied headache, dizziness, tingling, numbness, anxiety, nervousness, depression and insomnia. (R. at 391, 409.) On physical examination, Taylor was alert and oriented and in no acute distress. (R. at 391, 409.) No. deformities or muscle wasting was noted, but osteoarthritis was present. (R. at 392, 410.) Taylor had a normal gait and no joint dislocation, instability or subluxations. (R. at 392, 410.) Muscle strength was full, and he had a normal range of motion without pain or crepitus. (R. at 392, 410.) There was no clubbing, cyanosis or edema of the extremities, and knee, ankle and bicep tendon jerks were 2. (R. at 392, 410.) There were 2 dorsalis pedis and posterior tibial pulses, negative Homan's sign, and Taylor ambulated without difficulty. (R. at 392, 410.) He had normal respiratory, cardiovascular and neurological examinations. (R. at 392, 410.) Taylor's abdomen was soft and nondistended, without ascites and obvious hernias. (R. at 392, 410.) There was no tenderness, guarding or rebound tenderness to palpation. (R. at 392, 410.) There also was no evidence of hepatosplenomegaly, no palpable masses and no costovertebral angle, (“CVA”), tenderness. (R. at 392, 410.) Dr. Patel diagnosed Taylor with left lower quadrant abdominal pain, constipation, noninsulin dependent diabetes mellitus, hypertension, hyperlipidemia and osteoarthritis. (R. at 393, 411.) He ordered lab work and a colonoscopy. (R. at 393, 411.)

         On February 20, 2015, Taylor was admitted to Buchanan General Hospital for a screening colonoscopy. (R. at 390, 395-96, 404-06.) He did well post-operatively and was discharged home. (R. at 390, 395, 404, 406.) Taylor was diagnosed with diverticulosis coli and mild inflammation of the cecum. (R. at 390, 395, 404, 406.) He returned to Dr. Patel on February 27, 2015, for a follow-up appointment. (R. at 400-02.) Taylor was alert, oriented and in no acute distress. (R. at 400.) There were no deformities or muscle wasting, but osteoarthritis was present. (R. at 401.) A physical examination yielded the same findings as previously. (R. at 401.) Dr. Patel noted that Taylor's colonoscopy showed mild inflammation in the cecum, but a biopsy was negative. (R. at 402.) He diagnosed Taylor with left lower quadrant abdominal pain, constipation, chronic back syndrome, hyperlipidemia, hypertension and osteoarthritis. (R. at 402.) He recommended a high-fiber diet and a repeat colonoscopy in five years. (R. at 402.)

         On March 11, 2015, Taylor returned to Family Care Center. (R. at 419.) Chronic bilateral lower extremity burning, tingling and numbness was noted. (R. at 419.) A physical examination was within normal limits. (R. at 419.) Taylor was diagnosed with osteoarthritis, hyperlipidemia, hypertension, polyarthropathy and neuropathy. (R. at 419.)

         Taylor saw Dr. Belal Said, M.D., at Pikeville Medical Center on March 12, 2015, with complaints of joint pain, worse in the knees, legs and back and associated with subjective swelling. (R. at 484-91.) Taylor stated that the pain was worse with activities and decreased with rest. (R. at 484.) He also stated that it was worse in the evening and associated with numbness in the legs, without history of stool or urine incontinence. (R. at 484.) Taylor's blood pressure was 155/96. (R. at 485.) He rated his pain as a five on a 10-point scale. (R. at 486.) A physical examination was largely normal, except for crepitation of both knees and trace pitting edema of both lower extremities. (R. at 486.) Dr. Said diagnosed Taylor with joint pain, site unspecified, and he ordered lab work. (R. at 487.) Taylor was continued on his medications, which included aspirin and gabapentin. (R. at 487-88.) X-rays of Taylor's knees, taken on March 12, 2015, showed mild tricompartmental osteoarthritis in both knees. (R. at 414, 482.) A chest x-ray, taken the same day, showed no acute cardiopulmonary process, but mild age-indeterminate wedge deformity of the L1 disc. (R. at 417, 480.) Taylor returned to Dr. Said on April 14, 2015, with complaints of joint pain in both legs, which he rated as a six on a 10-point scale. (R. at 492-99.) He described the pain as aching and burning, and he stated it was aggravated by walking and standing and was worse in the mornings. (R. at 492.) Taylor stated that the pain was relieved by medication. (R. at 492.) Taylor's blood pressure was 130/78. (R. at 493.) A physical examination was normal, except for a mildly reduced range of motion of the right elbow and crepitation of both knees. (R. at 494.) Dr. Said diagnosed Taylor with osteoarthrosis, unspecified whether generalized or localized, involving unspecified site, and he was advised to continue taking diclofenac. (R. at 494.)

         Taylor returned to Family Care Center on August 17, 2015, with complaints of leg and finger cramps. (R. at 500.) He was alert and oriented with an appropriate affect. (R. at 500.) Taylor had a full range of motion of the extremities without edema, and he exhibited normal reflexes. (R. at 500.) He had increased burning and tingling in both lower extremities. (R. at 500.) He was diagnosed with lower back pain, polyarthropathy, neuropathy, hypertension and GERD. (R. at 500.) On September 23, 2015, Taylor's blood pressure was 112/72. (R. at 501.) He had bilateral knee crepitus and positive bilateral straight leg raise testing. (R. at 501.) Taylor was diagnosed with lower back pain, bilateral knee pain and polyarthropathy. (R. at 501.) His dosage of Norco was increased, and he was prescribed a course of prednisone. (R. at 501.) On October 9, 2015, Taylor again had bilateral knee crepitus, as well as paraspinal muscle tenderness. (R. at 502.) He was diagnosed with hyperlipidemia, lower back pain and polyarthropathy. (R. at 502.) On October 15, 2015, Taylor complained of achy and persistent pain in both legs and feet, which he rated as a six on a 10-point scale. (R. at 512.) He stated that it was aggravated by standing and relieved by rest. (R. at 512.) Taylor also complained of increased pain in the hands with numbness, as well as knee pain, for which he was taking Norco. (R. at 512.) Although he was still taking diclofenac, he did not think it was helping. (R. at 512.) Taylor was diagnosed with polyosteoarthritis, unspecified, and carpal tunnel syndrome of the arm. (R at 512.) Diclofenac was discontinued, and he was prescribed nabumetone. (R. at 512.) Taylor was advised to try wrist braces for the carpal tunnel symptoms, and a nerve conduction study would be considered for both hands. (R. at 512.) A complete metabolic panel and sedimentation rate testing were ordered. (R. at 512.) On October 22, 2015, Taylor's blood pressure was 128/80. (R. at 503.) He had bilateral knee crepitus, as well as cervical spine, thoracic spine and lumbar spine paramuscle tenderness. (R. at 503.) He also complained of increased burning and tingling in the lower extremities and feet, which he rated a 10 on a 10-point scale. (R. at 503.) Taylor was diagnosed with lower back pain, osteoarthritis, bilateral peripheral neuropathy, polyarthropathy and sciatica. (R. at 503.) Spinal x-rays were ordered, and Taylor's dosage of Norco was increased. (R. at 503.)

         On September 8, 2015, Taylor saw Dr. Nasreen Dar, M.D., a psychiatrist, for a psychiatric evaluation. (R. at 515-17.) He reported back pain for 12 to 15 years, but no history of back injury. (R. at 515.) Taylor stated that he had been diagnosed with degenerative disc disease in his back. (R. at 515.) He reported that his back continued to hurt, with pain radiating down both legs and a burning sensation in both feet. (R. at 515.) Taylor reported difficulty bending over, lifting heavy objects, sitting, standing or walking for too long. (R. at 515.) Taylor also reported diagnoses of hypertension and arthritis, for which he was taking medication. (R. at 515.) He further reported being nervous for the past several years, having difficulty dealing with stress, crowds, loud noises and children. (R. at 515.) He expressed feelings of irritability, depression and worry and having difficulty going to sleep and being restless during the night. (R. at 515.) Taylor reported that his appetite was fair without any weight change. (R. at 515.) He reported feelings of hopelessness, helplessness and worthlessness, and he admitted to suicidal ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.