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Caldwell v. Berryhill

United States District Court, E.D. Kentucky, Southern Division, London

March 10, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Danny C. Reeves United States District Judge

         This matter is pending for consideration of cross-motions for summary judgment filed by Plaintiff Jason Caldwell (“Caldwell” or “the Claimant”) and Defendant Nancy A. Berryhill, Acting Commissioner of Social Security (“the Commissioner”). [Record Nos. 20, 21');">1] Caldwell contends that the administrative law judge (“ALJ”) assigned to his case erred by denying his claims for disability income benefits (“DIB”) and supplemental security income (“SSI”). [Record No. 20-1');">1] He requests that the Court direct a finding of disability or, alternatively, remand the matter for further administrative proceedings before a new ALJ. [Record No. 20-1');">1, p. 1');">12] The Commissioner contends that the ALJ’s decision is supported by substantial evidence and should be affirmed. For the reasons discussed below, the Court will grant the Commissioner’s motion and deny the relief sought by Caldwell.

         I. Procedural History

         On March 22, 201');">10, Caldwell filed concurrent applications for a period of disability and DIB under Title II of the Social Security Act (“the Act”) and SSI under Title XVI of the Act. [Administrative Transcript, “Tr.,” 374, 379] Caldwell alleged that his disability began March 5, 201');">10. [Tr. 4] The Social Security Administration (“SSA”) denied his applications initially and upon reconsideration. [Tr. 1');">169–96] Caldwell requested an administrative hearing before an ALJ, who issued a written decision denying benefits on August 1');">1, 201');">11');">1. [Tr. 200– 209] He sought review by the Appeals Council, which was denied. [Tr. 21');">14]. Caldwell appealed to the United States District Court for the Eastern District of Kentucky. However, the Commissioner moved to remand the case pursuant to sentence six of 42 U.S.C. § 405(g) because significant portions of the audio recording of the ALJ hearing were inaudible. [Record No. 8] This Court remanded the matter for further administrative proceedings. [Record No. 9]

         Upon remand, ALJ Don Paris conducted a new hearing on August 5, 201');">14. [Tr. 21');">1] ALJ Paris issued a written decision denying benefits on August 22, 201');">14. [Tr. 4–1');">15] Caldwell filed for review with the Appeals Council, which was denied on April 1');">14, 201');">16. [Tr. 789] Accordingly, the claimant has exhausted his administrative remedies and this matter is ripe for review under 42 U.S.C. §§ 405(g), 1');">1383(c)(3).

         II. Background

         Caldwell was 39 years-old at the time of the ALJ’s decision and has a high school education. [Tr. 1');">14–1');">15] He attended special education classes and graduated from high school in 1');">1994. [Tr. 26, 45] He also has some vocational training in mining, but never worked in that field. Id. Caldwell was employed previously as a bus monitor, janitor, security guard, and in a farm supply store. [Tr. 26–29] He stopped working in March 201');">10. [Tr. 597] At the time of the administrative hearing, Caldwell lived with his parents and he held a driver’s license, which he used to drive to church and to shop. [Tr. 25]

         Caldwell contends that he is unable to work due to pain in his neck and low back, which began after an automobile accident in 2003. [Tr. 30] He required neck surgery following the car accident and has been treated with narcotics for more than ten years. [Tr. 34–36] Caldwell reports that the accident also resulted in a skull fracture, head injuries, and inner ear damage. [Tr. 635] As a consequence, he contends, he has trouble hearing, as well as a mental condition that prevents him from concentrating and following directions. [Tr. 598]

         Caldwell reported being five feet, four inches tall and weighing 245 pounds. [Tr. 25] He testified that he did not walk or exercise on a regular basis, but believed that he could walk and stand for approximately 30 minutes before stopping to rest. [Tr. 37] He further testified that he was only able to sleep between two and three hours each night. [Tr. 39] Caldwell denied having been treated by a mental health professional and denied needing such treatment. [Tr. 40]

         On May 29, 201');">10, Helen O’Donnell, M.D., examined Caldwell regarding his allegations of physical disability. [Tr. 640] Dr. O’Donnell report begins by recounting Caldwell’s subjective complaints, which included neck and low back pain, as well as left shoulder pain. [Tr. 640–41');">1] Caldwell also complained of intermittent numbness of both hands and hearing loss. [Tr. 641');">1] Additionally, Caldwell and his father told Dr. O’Donnell that Caldwell cannot perform “life skills” independently. Id. Caldwell reportedly relies on his parents for assistance managing money and is not fully literate. Id.

         Upon examination, Dr. O’Donnell found that Caldwell’s hearing was appropriate for conversation, although there was decreased perception of finger rub on the right. [Tr. 642] O’Donnell noted tenderness upon palpation of the musculature of the neck and back. Id. Although Caldwell’s grip strength was normal, he was unable to complete strength testing of the left arm, complaining of shoulder fatigue and neck pain. Id. Range of motion was limited in both shoulders and lower extremities. Id. Caldwell was able to squat and return to standing, but with pain. [Tr. 643] His toe and heel walking were symmetrical. Id. Caldwell was able to get up from a chair and get onto an examination table without assistance. Id.

         O’Donnell concluded that Caldwell had the ability to perform activities involving sitting which allow frequent changing of position and appropriate breaks that did not involve the use of his head in extension and the rotation of his low back. [Tr. 643] Further, she believed Caldwell could walk short distances and stand for short periods of time. Id. Repetitive bending, squatting, kneeling, and lifting overhead, however, would all likely increase pain. Id. Any weight bearing activity (such as standing, walking, lifting, carrying, pushing, and, pulling) would be expected to increase symptoms of back and leg pain. Id. Dr. O’Donnell noted that Caldwell understood instructions with some repetitions and responded appropriately to all requests, even when uncomfortable. [Tr. 643–44]

         On July 28, 201');">10, Carlos Hernandez, M.D., reviewed Caldwell’s file and provided his opinion regarding Caldwell’s residual functional capacity (“RFC”). [Tr. 1');">178–1');">183] He opined that Caldwell could occasionally lift and carry 20 pounds and could frequently lift and carry 1');">10 pounds. [Tr. 1');">178] Hernandez believed that Caldwell could stand, walk, and sit approximately six hours in an eight hour work day. Id. Further, he indicated that Caldwell could occasionally climb ramps and stairs, could occasionally crouch, kneel, and stoop, but that he could never climb ladders, ropes, or scaffolds. [Tr. 1');">179]

         On September 1');">10, 201');">10, Caldwell’s treating physician, Dr. Jeff Prater, provided a functional capacity assessment. [Tr. 674–678] On July 1');">17, 201');">14, Dr. Prater, provided a deposition to Caldwell’s attorney regarding Caldwell’s functional abilities. [Tr. 765] As of July 201');">14, Prater had been treating Caldwell for approximately fifteen years. [Tr. 771');">1] Most recently, Prater had treated him for high blood pressure and allergies, as well as pain, for which he prescribed hydrocodone, Flexeril, and Meloxicam. [Tr. 766] Prater diagnosed Caldwell with fibromyalgia based on pain and the presence of trigger points in the neck and low back. [Tr. 767] He testified that Caldwell had carpal tunnel syndrome, based on a positive ...

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