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Fields v. Berryhill

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

June 20, 2018

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 Toshia Renee Fields and Defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration. [Record Nos. 11, 13] Fields argues that the Administrative Law Judge (“ALJ”) assigned to her case erred in concluding that she was not disabled within the meaning of the Social Security Act (“Act”). Specifically, she asserts that the ALJ did not properly consider the opinion evidence and that the ALJ's decision is not supported by substantial evidence. Fields asks the Court to direct the Commissioner to award her benefits or, alternatively, remand this matter to the Commissioner for further consideration. The Commissioner contends that the ALJ properly evaluated the evidence and that the ALJ's decision should be affirmed because it is supported by substantial evidence.

         Having reviewed the record and the parties' arguments, the Commissioner's motion will be granted and Fields' motion will be denied for the reasons that follow.

         I. Procedural History

         Fields filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Act on April 4, 2013. [See Administrative Transcript, hereinafter “Tr., ” 280.] The application was denied initially and on reconsideration. Fields then requested a hearing before an ALJ. [Tr. 169, 174, 182] She appeared before ALJ Karen R. Jackson at an administrative hearing in Frankfort, Kentucky in March 2015. [Tr. 54-84] ALJ Jackson denied benefits in a written decision the following month. [Tr. 144-56] However, the Appeals Council vacated the ALJ's decision and remanded the matter for further consideration. [Tr. 163-65] ALJ Jackson held an additional hearing on October 26, 2016. [Tr. 29-53] She issued a written decision in March 2017, once again denying benefits. [Tr. 8-22] This time, the Appeals Council affirmed the decision. [Tr. 1-3] Accordingly, the claimant has exhausted her administrative remedies and this matter is ripe for review under 42 U.S.C. § 405(g).

         II. Background

         Fields was forty-five-years-old at the time of her application for benefits. [See Tr. 280.] She has a high school education and has worked for approximately five years as a school bus driver. [Tr. 306] She alleges that she became unable to work in April 2012 because of severe complications from neck surgery. [Tr. 280, 305]

         During her second hearing before the ALJ, Fields reported significant pain in her neck, right shoulder, and right hip. [Tr. 38] Fields stated that, after being on her feet for about twenty minutes, her neck and upper back muscles became very weak. [Tr. 39] She reported having attempted physical therapy following her neck surgery in 2012, but it caused increased swelling and pain.

         Fields' primary care provider, Anthony Yonts, D.O., completed an “arthritis questionnaire” in February 2015. [See Tr. 464, 534, 536, 538-39, 593-98.] Yonts reported that he saw Fields for chronic neck pain and “DJD” every two months. [Tr. 593] He commented that she experienced fatigue, palpitations, chronic neck pain, and that Fields had severe limitations with respect to activities of daily living. [Tr. 593] Yonts identified the following “objective” signs in support of his determination: reduced cervical range of motion; reduced grip strength; sensory changes; reflex changes; impaired sleep; abnormal posture; tenderness; crepitus; and muscle spasm. [Tr. 594] He ultimately concluded that Fields was unable to perform even “low stress jobs” because she could not turn her neck fully and could not use her upper extremities consistently. [Tr. 595]

         Yonts assessed the following specific limitations: Fields was unable to sit or stand for more than 30 minutes; she was unable to sit, stand, or walk for more than two hours per day; she could never lift more than ten pounds; could rarely lift less than ten pounds; she could never twist, crouch, or climb ladders, and could rarely stoop or climb stairs. [Tr. 595-97]

         Fields also received primary care in 2014 and 2015 at Quantum Healthcare. Practitioners Christopher Lewis and Ashley Taylor treated Fields for neck, shoulder, and back pain. [Tr. 549-50, 655] Taylor observed in May 2015 that Fields was unable to elevate her right shoulder above 90 degrees and could not elevate her left shoulder above 100-110 degrees. [Tr. 656]

         Chih Yen, DPM, treated Fields for sesamoiditis and flexor tendinitis of the right lower extremity in June 2012. [Tr. 406-07] An MRI report indicated that there was “evidence of edema, ” but Yen characterized the MRI as “completely normal.” [Tr. 406, 410] Accordingly, Yen suspected a “radiculopathy component” of the pain and advised Fields to “take care of her back.” Id. A doppler examination revealed no evidence of decreased blood flow in Fields' lower extremity arterial structures. [Tr. 411]

         Fields underwent an MRI of the cervical spine in May 2012, which revealed disc herniation at multiple levels. [Tr. 540-41] She consulted with a surgeon, Thomas Menke, M.D., the following month. [Tr. 536] Following an unsuccessful course of physical therapy, Menke performed decompression and multilevel fusion surgery. [Tr. 531] Fields continued to follow-up with Menke after the surgery. Although she continued to have some degree of discomfort, Fields experienced overall improvement, particularly with respect to the right upper extremity radiculopathy she had previously experienced. [Tr. 464-85, 524-32, 537, 557-59, 569-71, 589-92, 663-81]

         An MRI performed in April 2013 revealed mild residual foraminal stenosis and diffuse disc bulging, but no apparent nerve impingement at any level. [Tr. 464, 515] An additional MRI was performed in May 2015, which showed fusion of the C4, C5, C6, and C7 vertebral bodies with an anterior plate and screws. [Tr. 608] There was a small posterior disc osteophyte complex between C4-C5, C5-C6, C6-C7, and C7-T1, which was indenting on the thecal sac. Id. Menke noted that ...

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