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Brown v. Berryhill

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

October 24, 2018

BRIAN D. BROWN, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff has filed this action challenging the final decision of the Commissioner of Social Security denying plaintiffs claims for disability insurance benefits and supplemental security income benefits under the Social Security Act, as amended, 42 U.S.C. §§ 416(i) and 423, and 42 U.S.C. § 1381 et seq., respectively. Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). This court's review is limited to a determination as to whether there is substantial evidence to support the Commissioner's conclusion that plaintiff failed to meet the requirements for entitlement to benefits under the Act. If such substantial evidence exists, the final decision of the Commissioner must be affirmed. Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966). Stated briefly, substantial evidence has been defined as such relevant evidence, considering the record as a whole, as might be found adequate to support a conclusion by a reasonable mind. Richardson v. Perales, 402 U.S. 389, 401 (1971).

         The plaintiff, Brian D. Brown, was born on April 8, 1971. He did not graduate from high school but eventually earned a GED. Mr. Brown has been employed as a warehouse worker, automotive accessory installer, and truck driver. (Tr. 30, 231). He last worked on a regular and sustained basis in 2014. (Tr. 29, 231). On April 7, 2014, Mr. Brown filed applications for disability insurance benefits and supplemental security income benefits. In filing his current claims, Mr. Brown alleged that he became disabled for all forms of substantial gainful employment on March 31, 2014, due to back problems and arthritis. (Tr. 230). At the time of an administrative hearing on October 25, 2016, plaintiff amended his applications so as to reflect an alleged disability onset date of January 1, 2016. (Tr. 30). Mr. Brown maintains that he has remained disabled to the present time. With respect to his application for disability insurance benefits, the record reveals that Mr. Brown met the insured status requirements of the Act at all relevant times covered by the final decision of the Commissioner. See generally 42 U.S.C. §§ 416(i) and 423(a).

         Mr. Brown's applications were denied upon initial consideration and reconsideration. He then requested and received a de novo hearing and review before an Administrative Law Judge. In an opinion dated December 6, 2016, the Law Judge also determined, after applying the five-step sequential evaluation process, that Mr. Brown is not disabled. See 20 C.F.R. §§ 404.1520 and 416.920.[1] The Law Judge found that Mr. Brown suffers from several severe impairments, including dysfunction of the major joints, osteoarthritis and allied disorders, degenerative disc disease, lumbar spondylosis, and lumbar postlaminectomy syndrome, but that these impairments do not, either individually or in combination, meet or medically equal the requirements of a listed impairment. (Tr. 13-14). The Law Judge then assessed Mr. Brown's residual functional capacity as follows:

After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform a range of light work as defined in 20 C.F.R. [§§] 404.1567(b) and 416.967(b) except the claimant would retain the capacity to lift/carry twenty pounds occasionally and ten pounds frequently; sit for six hours in an eight hour workday; stand/walk six hours in an eight hour workday; pushing/pulling as much as lift/carry; occasionally use the right foot in operating of foot controls; frequently balance; and occasionally climb ramps and stairs, knee[l], stoop, crouch, and crawl. The claimant would additionally retain the capacity to withstand occasional exposure to unprotected heights, moving mechanical parts, and occasional operation of a motor vehicle.

(Tr. 14). Given such a residual functional capacity, and after considering testimony from a vocational expert, the Law Judge determined that Mr. Brown is unable to perform any of his past relevant work. (Tr. 17). However, the Law Judge found that Mr. Brown retains sufficient functional capacity to perform other work roles existing in significant number in the national economy. (Tr. 18). Accordingly, the Law Judge concluded that Mr. Brown is not disabled, and that he is not entitled to benefits under either federal program. See generally 20 C.F.R. §§ 404.1520(g) and 416.920(g). The Law Judge's opinion was adopted as the final decision of the Commissioner by the Social Security Administration's Appeals Council. Having exhausted all available administrative remedies, Mr. Brown has now appealed to this court.

         While plaintiff may be disabled for certain forms of employment, the crucial factual determination is whether plaintiff is disabled for all forms of substantial gainful employment. See 42 U.S.C. §§ 423(d)(2) and 1382c(a). There are four elements of proof which must be considered in making such an analysis. These elements are summarized as follows: (1) objective medical facts and clinical findings; (2) the opinions and conclusions of treating physicians; (3) subjective evidence of physical manifestations of impairments, as described through a claimant's testimony; and (4) the claimant's education, vocational history, residual skills, and age. Vitek v. Finch, 438 F.2d 1157, 1159-60 (4th Cir. 1971); Underwood v. Ribicoff, 298 F.2d 850, 851 (4th Cir. 1962).

         After a review of the record in this case, the court is constrained to conclude that the Commissioner's final decision is supported by substantial evidence. The record reveals that Mr. Brown received treatment for back pain from doctors at Coastal Spine & Pain Center in Jacksonville, Florida in 2013 and 2014, prior to his alleged onset date. On March 4, 2013, Mr. Brown received a thirty-day supply of prescription medication for back pain. (Tr. 312). Dr. Kenneth Powell noted that plaintiffs past medical history included a herniated disc, and that he had undergone a lumbar laminectomy at L4-L5 and a lower lumbar fusion. (Tr. 311). Although plaintiff continued to complain of pain at subsequent monthly appointments, examination notes indicate that he was "doing well," that the prescribed medications helped "improve pain and function," and that plaintiff was "stable on current medications." (Tr. 297, 302, 303, 305, 308).

         On August 19, 2013, Mr. Brown underwent a lumbar facet nerve block injection at Coastal Spine & Pain Center. X-rays of the lumbosacral spine were obtained prior to the procedure, which revealed "degenerative joint disease with no appreciable subluxations or fractures." (Tr. 295). Although Mr. Brown "tolerated the injections well without any complications or side effects," he complained of increased back pain in October and November 2013. (Tr. 285, 289, 295). Dr. Powell ultimately prescribed a fentanyl patch, which plaintiff found to be "very helpful" in controlling his pain. (Tr. 285). In February of 2014, Dr. Powell noted that plaintiff had "remained compliant with his medications" and reported "excellent pain control." (Tr. 272). Dr. Powell also noted that Mr. Brown would be starting a different job in Virginia the following week, and that he would forward his examination notes to Mr. Brown's new physician. (Tr. 272-73).

         On May 14, 2014, Mr. Brown presented to Ability Physical Medicine and Rehabilitation, Inc. in Blacksburg, Virginia, where he was seen by Dr. Richard Wilson. Plaintiff advised Dr. Wilson that he was "currently unemployed [and] considering application for social security disability," but that he also hoped to "possibly get[] back into youth coaching." (Tr. 317). Dr. Wilson noted that plaintiff demonstrated "some pain behaviors" during the appointment but did "not have a full histrionic disability presentation." (Tr. 317). On physical examination, plaintiff complained of leg and back pain, his reflex at the right Achilles was absent, and his straight leg raising test was "generally positive on the right" and "equivocal on the left." (Tr. 317). Dr. Brown noted that the examination was otherwise "pretty normal." (Tr. 317). He prescribed hydrocodone and tizanadine for pain, and recommended an "increase of exercise." (Tr. 318).

         On January 4, 2016, Mr. Brown sought treatment from Dr. Anthony Dragovich at Blue Ridge Pain Management Specialists in Salem, Virginia. Plaintiff primarily complained of pain in his lower back and right leg. (Tr. 320). He reported that the pain was aggravated by activity, but that he was "able to perform cooking, cleaning, and personal hygiene" activities. (Tr. 320). An examination of plaintiffs lumbosacral spine revealed decreased range of motion and some tenderness. (Tr. 322). However, the straight leg raising test was negative bilaterally and plaintiff exhibited normal paraspinal muscle strength and increased tone. Likewise, plaintiff displayed normal range of motion in his upper and lower extremities with no edema, tenderness to palpation, or pain on motion. (Tr. 322-23). Although plaintiffs gait was "antalgic," he was able to stand without difficulty. (Tr. 323). Dr. Dragovich diagnosed plaintiff with lumbar degenerative disc disease, lumbar postlaminectomy syndrome, lumbar spondylosis, and sacroiliitis. (Tr. 323). He performed a right sacroiliac joint injection that provided "some pain relief." (Tr. 323). Mr. Brown underwent a second injection on January 22, 2016. (Tr. 325).

         Mr. Brown returned to Dr. Dragovich for a follow-up appointment on February 25, 2016. At that time, plaintiff reported that the injections "were not helpful," that he was "still miserable," and that the pain was "greatly affecting his ability to do basic activities." (Tr. 330-31). Dr. Dragovich performed a physical examination that yielded findings consistent with the previous examinations. (Tr. 332). He prescribed hydrocodone-acetaminophen and cyclobenzaprine, and instructed plaintiff to return in one month. (Tr. 332-33).

         Subsequent progress notes from March, April, May, and July of 2016 indicate that the addition of hydrocodone-acetaminophine (Norco)[2] proved to be "helpful" and "without side effects!" (Tr. 334-45, 338-39, 342-43, 346-47). Although plaintiff continued to exhibit reduced range of motion in his lumbosacral spine, his musculoskeletal examinations were otherwise normal. (Tr. 336, 340, 344, 348). During a follow-up examination on September 16, 2016, plaintiff reported that his prescription for Norco was not working as well as it once did, and he inquired about adding a fentanyl patch. (Tr. 354). Dr. Dragovich "slightly" adjusted plaintiffs existing prescription, but declined to order a fentanyl patch since they were "managing his pain fairly well" with Norco. (Tr. 354).

         At the administrative hearing conducted the following month, Mr. Brown testified that he is in pain "24 hours a day," and that the pain "continuously interrupts his sleep" and causes him to require assistance "washing [his] lower extremities." (Tr. 32-33). Mr. Brown further testified that he is only able to cook simple meals approximately twice a week. (Tr. 34-35). Plaintiff estimated that he can stand approximately fifteen or twenty minutes before he needs to sit and stretch, and that he can sit for approximately ten minutes before he needs to readjust himself. (Tr. 36). Plaintiff also testified that he can only walk approximately fifty yards before he needs to stop, and that he is unable to bend over due to severe pain. (Tr. 38). ...

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