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Lee v. Berryhill

United States District Court, E.D. Kentucky, Central Division, Lexington

February 6, 2018

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



         Brad Collins Lee seeks judicial review of an administrative decision of the Commissioner of Social Security, which denied Lee's claim for disability insurance benefits. Mr. Lee brings this action pursuant to 42 U.S.C. § 405(g), alleging the ALJ decision is erroneous and not supported by substantial evidence, the ALJ decision is contrary to law, the ALJ applied incorrect standards, and the ALJ abused his discretion in judging the medical evidence and credibility of Lee's testimony. [R. 1.] The Court, having reviewed the record and for the reasons set forth herein, will DENY Mr. Lee's Motion for Summary Judgment [R. 9] and will GRANT the Commissioner's Motion for Summary Judgment [R. 11.]


         Plaintiff Brad Collins Lee filed an application for Title II disability insurance benefits (DBI) on February 18, 2014, alleging disability beginning January 29, 2014.[1] [Transcript (hereinafter, “Tr.”) 183.] Lee's claims were initially denied in July 2014, and then denied again upon reconsideration in September 2014. [See Tr. 25.] After requesting a hearing, Lee appeared and testified at a video hearing on December 22, 2015, in front of ALJ Jonathan Stanley. [Id.] Vocational expert Tina Stambaugh also testified. [Id.] The ALJ issued a final decision ultimately denying Lee's claims for benefits. [Tr. 38.]

         Brad Collins Lee was born on January 3, 1973. [Tr. 183.] He graduate high school and attended one year of college. [Tr. 203.] He is married and lives with his wife in Sadieville, Kentucky. [Tr. 201.] He has not worked since January 29, 2014. [Tr. 183; Tr. 202.] His employment history consists of working at pharmacies and grocery stores for approximately eleven years. [Tr. 203.]

         Mr. Lee alleges disability based on epilepsy, pericarditis, and depression. [Tr. 202.] Plaintiff began experiencing seizures related to his epilepsy at the age of thirteen; however, in 2013, his seizures intensified in frequency to approximately one per week from one per year. [Tr. 63-64, 455.] In April 2014, Lee underwent a procedure to have a Vagus Nerve Stimulator (VNS) implanted in his chest to better control the intensity and frequency of his seizures. [Tr. 437-39.] While Mr. Lee indicates that he “continues to have seizures during which he convulses, loses consciousness and loses bladder control” [R. 9-1 at 3], and the Court recognizes these events as normal for someone having seizures, Lee fails to indicate where in the record that information is objectively corroborated with regard to his epileptic episodes. In fact, in a follow up appointment on August 27, 2015, Mr. Lee indicated he had two seizures in the previous six months and on neither occasion experienced loss of bladder control. [Tr. 627.] The record, however, does corroborate the Commissioner's assertion that Mr. Lee's seizures reduced in number over a period of time following his VNS procedure. [R. 11 at 2-3; Tr. 455, 561, 627.] Mr. Lee reports his driver's license was removed by the Kentucky Department of Transportation due to his epilepsy. [R. 9-1 at 3.] However, again, Lee does not indicate where in the record that information is corroborated other than Mr. Lee's own testimony. [R. 9-1 at 3.] And while Mr. Lee indicates he must always have someone present with him in order to activate the VNS by magnet or administer nasal medication during a seizure [R. 9-1 at 3; Tr. 65-67], the Commissioner acknowledges as much. [See R. 11 at 2 n.2.]

         In addition to treatment for epilepsy, Mr. Lee has a history of pericarditis - the swelling and irritation of the membrane surrounding the heart. In late 2014 Lee experienced an aortic aneurysm. [Tr. 470.] In December 2014, Lee underwent surgery for ascending aortic replacement. [Tr. 470-72.] Following his surgery, Lee presented to Dr. Hassan K. Reda with increased energy and appetite, and Lee reported eating, sleeping, and ambulating well. [Tr. 526, 528.] In April 2015, Mr. Lee reported to Chris Oser, PA-C, and Dr. Travis Hunt complaining of a “frozen shoulder.” [Tr. 606.] While Mr. Lee reports this complication was a result of his heart surgery [R. 9-1 at 4], there is no objective medical evidence in the record to indicate the surgery was the cause of his ailment.

         Mr. Lee also has a history of mental health issues. He has received prescription medications related to depression [see Tr. 306, 308, 337, 454, 459, 546, 557, 564, 591], but the Court finds nowhere in the record a diagnosis of depression. Indeed, Mr. Lee denied having depression, anxiety, or other psychiatric issues on multiple occasions. [See Tr. 340, 378, 547, 558, 578, 597.] In June 2014, Dr. M. Maude O'Neill diagnosed Lee with bipolar I disorder and adjustment disorder with depressed mood. [Tr. 451.] In July 2015, Dr. James Wilson conducted a Medical Assessment of Ability to do Work-Related Activities (Mental) of Mr. Lee. [Tr. 552-55.] Dr. Wilson determined Lee to have “poor” abilities to deal with the public, use judgment, deal with work stresses, function independently, maintain attention/concentration, understand/remember/carry out simple job instructions, relate predictably in social settings, and demonstrate reliability. [Tr. 553-55.] However, a rating of “poor” does not indicate a person has no useful ability to function in the area; instead, a rating of “poor” indicates an “ability to function . . . is seriously limited but not precluded.” [Tr. 553.] Additionally, Dr. Wilson determined Lee to have a “fair” ability to function in the areas of following work rules, relating to co-workers, and interacting with supervisors. [Id.] A rating of “fair” indicates an “ability to function in this area is limited, but satisfactory.” [Id.] Lastly, Dr. Wilson opined negatively on Mr. Lee's ability to work full days. [Tr. 554.]

         In evaluating a claim of disability, the ALJ conducts a five-step analysis. See 20 C.F.R. § 404.1520. First, if a claimant is performing a substantial gainful activity, she is not disabled. 20 C.F.R. § 404.1520(b). Second, if a claimant does not have any impairment or combination of impairments which is severe and meets certain durational requirements, she is not “disabled” as defined by the regulations. 20 C.F.R. § 404.1520(c). Third, if a claimant's impairments meet or equal one of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, she is “disabled.” 20 C.F.R. § 404.1520(d). Before moving to the fourth step, the ALJ must use all the relevant evidence in the record to determine the claimant's residual functional capacity (“RFC”), which assesses an individual's ability to perform certain physical and mental work activities on a sustained basis despite any impairment experienced by the individual. See 20 C.F.R. § 404.1520(e); 20 C.F.R. § 404.1545. Fourth, the ALJ must determine whether the claimant has the RFC to perform the requirements of her past relevant work, and if a claimant's impairments do not prevent her from doing past relevant work, she is not “disabled.” 20. C.F.R. § 404.1520(e). Fifth, if a claimant's impairments (considering her RFC, age, education, and past work) prevent her from doing other work that exists in the national economy, then she is “disabled.” 20 C.F.R. § 404.1520(f).

         Through step four of the analysis, “the claimant bears the burden of proving the existence and severity of limitations caused by her impairments and the fact that she is precluded from performing her past relevant work.” Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003). At step five, the burden shifts to the Commissioner to identify a significant number of jobs that accommodate the claimant's profile, but the claimant retains the ultimate burden of proving her lack of residual functional capacity. Id.; Jordan v. Comm'r of Soc. Sec., 548 F.3d 417, 423 (6th Cir. 2008).

         In this case, at step one, the ALJ determined that Mr. Lee has not engaged in substantial gainful activity since October 1, 2013.[2] [Tr. 27.] At step two, the ALJ found Lee to have the following “severe” impairments: obesity, low back pain, left shoulder pain with history of adhesive capsulitis, history of Dupuytren's contractures of the bilateral hands and feet, history of right talus fracture, a seizure disorder - post left-side placement of vagus nerve stimulator, hypertension, cardiomyopathy, thoracic aortic aneurysm/chronic proximal ascending aortic dissection status - post aortic replacement and repair, adjustment disorder with depressed mood, bipolar disorder, impulse control disorder and anxiety. [Id.] At step three, the ALJ found Lee's combination of impairments do not meet or medically equal the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, App'x 1. [Tr. 28.] Before moving to step four, the ALJ considered the record and determined that Lee possessed the following residual functioning capacity:

[T]he claimant has the residual functioning capacity to perform light work as defined at 20 CFR 404.1567(b) except he can occasionally push and pull using the left upper extremity; can occasionally climb stairs and ramps, but cannot climb ropes, ladders and scaffolds; can occasionally balance, stoop, kneel, crouch and crawl; can occasionally reach overhead using the non-dominant left upper extremity; can frequently handle and finger bilaterally; can occasionally operate foot controls; cannot operate commercial vehicles; must avoid concentrated exposure to temperature extremes, humidity and vibration; cannot work at unprotected heights or around hazards such as heavy equipment; can understand, remember and carry out short, simple instructions and make simple work-related judgments; can maintain adequate attention and concentration to perform simple tasks on a sustained basis with normal supervision; can manage and tolerate simple changes in the workplace routine; and can adapt to the pressures of simple routine work.

[Tr. 19.] After explaining Lee's RFC, the ALJ found at step four that, based on this RFC, his age, education, and work experience, there are a “significant number[]” of jobs in the national economy that Lee can perform. [Tr. 37.] Accordingly, the ALJ found at step five that Mr. Lee has not been under a ...

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