Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Lee v. Berryhill

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

May 6, 2019

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


          Danny C. Reeves United States District Judge

         The plaintiff seeks judicial review of the Commissioner of Social Security's denial of his application for disability insurance benefits. Because her decision is supported by substantial evidence and is based on a proper application of the law, the Commissioner's decision will be affirmed.


         Plaintiff John Herbert Lee (“plaintiff” or “Lee”) filed an application for disability insurance benefits (“DIB”) on October 21');">1, 201');">16. [See Administrative Transcript; hereafter “Tr., ” 21');">17.] His application was disapproved initially and upon reconsideration. [Tr. 1');">134, 1');">139] Lee thereafter requested a hearing before an administrative law judge (“ALJ”). ALJ Joyce Francis held a hearing on November 9, 201');">17, and issued a written decision denying benefits on March 21');">1, 201');">18. [Tr. 76-99; 51');">1-68] The ruling became the Commissioner's final decision when the Appeals Council denied the plaintiff's request for review on October 1');">10, 201');">18. [Tr. 1');">1-6] Accordingly, this matter is ripe for judicial review. See 42 U.S.C. § 405(g).


         The plaintiff was 48 years old at the time of the ALJ's decision. He attended school through the eighth grade and attended special education classes. [Tr. 79] Thereafter, Lee performed skilled and semi-skilled work in the coal industry for more than 20 years, most recently hauling supplies in and out of mines. [Tr. 82, 92-93] He alleges that he became unable to work when he injured his right shoulder on July 9, 201');">15. [Tr. 81');">1-82, 21');">19] Because of this injury. Lee received workers' compensation benefits from July 29, 201');">15, through September 20, 201');">16. [Tr. 21');">14-1');">16] At the time of the administrative hearing, he lived alone, held a driver's license, and was able to drive himself for shopping two or three times per week. [Tr. 80]

         Lee advised the ALJ that pain in his shoulder, neck, and low back prevented him from working. [Tr. 84] He estimated that he could sit, stand, or walk for about ten minutes without changing positions, and could lift or carry about ten pounds. [Tr. 85] Lee was able to shower and dress himself, and prepare simple meals, but denied being able to do any housework. [Tr. 85] For social activities, he reported attending church once per week. [Tr. 86]

         Ben Kibler, M.D., treated Lee's shoulder injury beginning in October 201');">15. [Tr. 606] Lee underwent an MRI, which revealed a small supraspinatus tear. Dr. Kibler recommended physical therapy, but Lee did not improve significantly with conservative treatment. As a result, Kibler surgically repaired the supraspinatus on February 3, 201');">16. [Tr. 602] Lee remained off work and followed up with Kibler periodically until he attained maximum medical improvement in September 201');">16. [Tr. 589] While Lee complained of neck tightness and stiffness, Dr. Kibler concluded that he had no “true radicular symptoms.” [Tr. 592] Kibler reported, per Lee's functional capacity evaluation, that he could lift no more than 40 pounds to his waist and no more than 1');">12 to 1');">15 pounds overhead.

         Lee saw Chandrashekar Krishnaswamy, M.D., for neck and low back pain in April 201');">17. [Tr. 724-28] He rated his low back pain as a severity level of nine out of ten and complained that the pain radiated to his hip. While Lee's sensation and deep tendon reflexes were normal, Krishnaswamy suspected lumbar radiculopathy and recommended naproxen, Flexeril, and physical therapy.

         Lee returned to Dr. Krishnaswamy with complaints of neck pain in July 201');">17. [Tr. 71');">19] Krishnaswamy, however, did not detect any spine tenderness, and muscle tone and bulk were normal. Further, Lee's upper extremity strength was rated five-minus out of five, at worst, and his deep tendon reflexes were intact and symmetrical. An MRI of Lee's cervical spine was normal. [Tr. 720] Krishnaswamy prescribed Flexeril and recommended physical therapy.

         Lee has a history of alcoholism, depression, and suicidal ideations. He presented to the Harlan ARH emergency department while intoxicated on three occasions between December 201');">14 and September 201');">16. Lee was briefly hospitalized each time and was encouraged to follow up with medication and counseling. [Tr. 361');">1-557] Psychiatrist Syed Raza, M.D., treated Lee on an outpatient basis beginning in September 201');">16 and diagnosed major depressive disorder and alcohol dependency. [Tr. 761');">1] Raza prescribed Vistaril and Paxil and recommended bi-monthly counseling. [Tr. 762] By August 201');">17, Lee still experienced stress and feelings of uselessness, but he had attended some counseling sessions. Additionally, he was taking his prescribed medication and his depression and anxiety had improved. [Tr. 732, 750] Lee advised the ALJ during his administrative hearing that he had not consumed alcohol in two years. [Tr. 90]

         Ravi Jayavarapu, M.D., performed a consultative examination in December 201');">16. [Tr. 623] Lee advised Jayavarapu that he was most limited by right shoulder and low back pain. Jayavarapu observed that Lee had mild difficulty getting on and off the examination table but exhibited normal posture and gait. [Tr. 624] Lee's right shoulder range of motion was reduced, with flexion limited to 1');">11');">10 degrees and abduction limited to 70 degrees. Lee was unable to extend his lumbar spine past neutral, but could flex to 70 degrees. Jayavarapu noted that Lee's cervical range of motion was within normal limits. [Tr. 627]

         Jayavarapu concluded that Lee could perform activities involving sitting, standing, moving about, lifting, carrying, and handling objects with his left hand. He found it was reasonable that Lee would have mild to moderate difficulty sitting or standing for prolonged periods, or lifting, carrying, and handling objects with his right hand. Although Lee had limited motion in his right shoulder, his strength was five out of five in all extremities. [Tr. 626]

         Leigh Ford, Ph.D., performed a consultative psychiatric examination on December 1');">19, 201');">16. [Tr. 630] She noted that Lee was fully oriented and could recall recent and remote events. His affect appeared flat and his mood was pessimistic, as he continued to struggle with feelings of depression. However, Lee exhibited normal speech and denied experiencing hallucinations. While his organization of thought was logical and goal-oriented, he had some gaps in insight and had trouble making decisions. [Tr. 631');">1] Ford administered the ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.