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Phillips v. Berryhill

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

March 29, 2019




         Plaintiff Robbie Lee Phillips brings this matter under 42 U.S.C. § 405(g) seeking judicial review of an administrative decision of the Acting Commissioner of Social Security. Specifically, the Plaintiff claims that the Administrative Law Judge (“ALJ”) failed to consider relevant medical evidence in the record and failed to consider the entire record, constituting reversible error. The Court, having reviewed the record and the cross motions for summary judgment filed by the parties, will AFFIRM the Commissioner's decision because the ALJ provided enough information in her written decision to demonstrate that she made a reasoned decision that is supported by substantial evidence in the record.

         I. Standard for Determining Disability

         Under the Social Security Act, a disability is defined as “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). In determining disability, an Administrative Law Judge (“ALJ”) uses a five-step analysis. See Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003). Step One considers whether the claimant is still performing substantial gainful activity; Step Two, whether any of the claimant's impairments are “severe”; Step Three, whether the impairments meet or equal a listing in the Listing of Impairments; Step Four, whether the claimant can still perform past relevant work; and, if necessary, Step Five, whether significant numbers of other jobs exist in the national economy which the claimant can perform. As to the last step, the burden of proof shifts from the claimant to the Commissioner. Id.; see also Preslar v. Sec'y of Health & Human Servs., 14 F.3d 1107, 1110 (6th Cir. 1994).

         II. Procedural and Factual History

         Phillips filed an application for disability insurance benefits (DIB) and supplemental security income (SSI) on March 18, 2014, alleging disability as of May 5, 2011. [TR 199]. Phillips alleged disability due to lower back pain, depression, high blood pressure, and anxiety. [TR 225]. Phillips's application was denied initially and upon reconsideration. [TR 1-7].

         A. Relevant Medical Evidence

         (1) Medical Evidence Related to Back and Leg Pain

         Phillips submitted medical evidence from his primary care physician, Dr. Stephen Green. Dr. Green treated Phillips for back and leg pain, depression, and anxiety. [TR 296-457, 460-68, 576-90, 602-29, 649-57]. Phillips was also treated on numerous occasions by an advanced practice registered nurse (“APRN”), Leann Brown, who worked with Dr. Green. [See generally id.].

         In 2011, Phillips presented to Dr. Green with severe leg and back pain. [TR 306]. Dr. Green's examination notes report but that Phillips had “good flexion and extension and lateral bending of the spine and rotation, but stiffness [was] noted in all these joints.” [TR 306]. Phillips was prescribed Lortab, Flexeril, Naprosyn, and a tapering dose of Prednisone. [Tr 305].

         An MRI study was conducted on Phillips's lumbar spine. The MRI showed disc protrusions of differing sizes at ¶ 4/5 and L5/S1 and “facet hypertrophy resulting in moderate bilateral neural foraminal stenosis.” [TR 456]. Dr. Green adjusted Phillips's medications to control his back pain and referred Phillips to a neurologist. [TR 303-04].

         Subsequently, Phillips was treated by Dr. James R. Bean, a neurosurgeon. [TR 469-71]. Dr. Bean noted that Phillips complained of back pain that radiated to his legs and bothered him whether he is standing, sitting, or lying down. [TR 470]. Dr. Bean determined that the MRI showed a degenerative disc bulge at ¶ 4-5 and a mild degenerative disc at ¶ 5-S1. [TR 469]. Still, Dr. Bean said that, “There is no instability, stenosis, dural or nerve root compression or other correctible cause of back pain. Unfortunately, there is little I have to offer him for his back[-]pain problem.” [Id.].

         Phillips continued treatment with Dr. Green, who noted tenderness at the L4 to S2 vertebrae. [TR 300]. Moreover, Phillips reported that he was unable to work due to his back pain. [Id.]. Dr. Green recommended that Phillips apply for disability benefits due to “multiple problems.” [Id.].

         In October 2011, Phillips completed a state agency pain and daily activities questionnaire. [TR 232-36]. Phillips reported pain all over but that the pain was particularly severe in his lower back and legs. [TR 232]. Furthermore, Phillips reported taking numerous medications but indicated that the medication does not completely relieve his pain. [TR 233]. Phillips also stated that he had worked in construction but had to quit due to his pain and that he struggled putting his shoes and socks on but that he did perform some householdchores infrequently. [TR 235].

         In late 2011, Phillips saw Dr. Anjum Bux, an anesthesiologist and pain management specialist, for severe pain radiating from his lower back down both legs. [TR 482]. Dr. Bux treated Phillips with two lumbar epidural steroid injections. [TR 479-80, 472-73].

         In early 2012, Dr. Green noted that Phillips had low back tenderness with reduced range of motion, but that Phillips had full leg strength. [TR 298]. Dr. Green continued to treat Phillips's constant back pain with various prescription medications, including Lortab, Methadone, Naprosyn, and Flexeril. [TR 298]. Still, at this medical visit, Dr. Green noted that “Robbie looks better. He is more perky. He is making eye contact and actually ...

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