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Brandt v. Saul

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

July 23, 2019

PAMELA JEAN BRANDT, Plaintiff,
v.
ANDREW M. SAUL, Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          DANNY C. REEVES, UNITED STATES DISTRICT JUDGE

         The Commissioner of Social Security (“Commissioner”) denied Plaintiff Pamela Jean Brandt's application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”). Brandt appealed the Commissioner's decision to this Court, and the parties have now filed cross-motions for summary judgment. [Record Nos. 11, 13]

         Brandt contends that the Commissioner's decision should be reversed because the Administrative Law Judge (“ALJ”) assigned to her case did not follow the applicable law in deciding whether she was entitled to benefits. Conversely, the Commissioner maintains that the decision should be affirmed because the ALJ applied the law correctly and the decision denying benefits is supported by substantial evidence. For the reasons that follow, the Commissioner's motion will be granted and Brandt's motion will be denied.

         I. Procedural History

         Brandt filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Act on January 25, 2016. [See Administrative Transcript, hereinafter “Tr., ” 108, 306.] Brandt requested an administrative hearing before an ALJ after her application was denied initially and on reconsideration. [Tr. 237, 248, 256] She appeared before ALJ Karen Jackson in Lexington, Kentucky in January 2018. [Tr. 153-204] Following this hearing, Jackson denied benefits in a written decision dated May 7, 2018. [Tr. 105-23] The Appeals Council affirmed the decision in December 2018, making this matter is ripe for review under 42 U.S.C. § 405(g). [Tr. 1-4]

         II. Background

         Brandt was 54 years old at the time of the ALJ's decision. She reported that she became unable to work on August 17, 2015, due to neck pain, migraines, and stress following the death of her 29-year-old son in 2014. [Tr. 324, 958] Brandt resided with her 86-year-old mother, who she assisted with some activities of daily living. [Tr. 180, 351] She also helped care for her three young grandchildren, but reported that she was forced to terminate that assistance in late 2017 because she “couldn't handle it anymore.” [Tr. 182]

         Brandt advi sed ALJ Jackson that she had a driver's licens e, but occasionally had trouble driving due to migraines and seizures. [Tr. 158] She was able to do some household cleaning and prepare some meals. She reported going grocery shopping twice per month, and enjoyed watching television several times per day. [Tr. 350] Brandt socialized with her adult daughter, as well as a friend who she saw once or twice a month. [Tr. 354]

         Brandt has an associate degree in business administration, with an emphasis in medical billing and coding. [Tr. 158] From January 2012 through September 2015, she performed administrative work in which she was required to lift up to 20 pounds. [Tr. 159-60] And prior to this employment, she worked in healthcare billing, at a call center, and at L-3 Communications, where she was required to lift up to 80 pounds. [Tr. 161-64]

         Brandt's primary care provider, Usha Gutti, M.D., treated her for neck and back pain, fibromyalgia, headaches, depression, anxiety, and seizures. Gutti prescribed various medications for these problems, including Baclofen, Neurontin, Norco, Topamax, Savella, Restoril, trazadone, and ibuprofen. [Tr. 635] Gutti referred Brandt to neurosurgeon Gabriel Phillips, M.D, for neck and low back pain in March 2016. Phillips noted that, while Brandt reported tenderness upon palpation of her cervical and lumbar spine, objective testing such as straight leg raising and reflexes was normal. A lumbar MRI revealed a broad based disc protrusion at ¶ 5-S1, with mild bilateral foraminal stenosis. Phillips described the results of the MRI as “unremarkable.” [Tr. 625] Phillips instructed Brandt to continue physical therapy. [Tr. 628-29]

         Brandt underwent a successful cervical fusion at the C5-6 level in 2006, but complained that her pain had progressively returned. [Tr. 680] Gutti referred Brandt to a second neurosurgeon, C. Benjamin Newman, M.D, in July 2016. [Tr. 677] Newman remarked that Brandt had fibromyalgia and that there was “no clear MRI correlate to her pain syndrome.” [Tr. 679] He also reported that Cymbalta was helping to relieve Brandt's pain and that surgery was not indicated. A neck x-ray taken in January 2018 revealed some degenerative changes including mild narrowing of the C4-5 and C6-7 disc spaces. [Tr. 1455]

         Dr. Gutti referred Brandt to Donald Douglas, M.D., of Advanced Pain Medicine in September 2016. [Tr. 837] Douglas educated Brandt regarding positive lifestyle changes and scheduled therapeutic injections for her neck and low back pain. For unknown reasons, Gutti referred Brandt to a different pain management specialist, Joshua Bailey, M.D., in October 2016. [Tr. 893] Bailey noted Brandt's complaints of pain “all over” and that previous physical therapy and chiropractic treatment had not provided significant relief. Bailey observed that Brandt's gait was non-antalgic and that her extremity and trunk range of motion was normal. He diagnosed her with fibromyalgia and SI joint dysfunction, provided an injection to the SI joint, and recommended that she wean from opiate use. [Tr. 898, 903]

         Brandt saw neurologist Aleksandr Mogilevski, M.D., for neck pain and headaches in March 2017. [Tr. 690] Mogilevski noted that Brandt's lateral neck motion was restricted by diffuse muscle spasms “with tenderness from both occipital nerves.” [Tr. 691] He referred brandt back to Dr. Douglas for a possible occipital nerve block. [Tr. 692]

         Brandt returned to Douglas in May 2017, complaining of constant head pain that interfered with daily activities, including her ability to sleep. [Tr. 1030] Douglas noted that Brandt's neck range of motion was adequate, but that she reported muscle tenderness upon palpation. [Tr. 1032-33] Douglas provided therapeutic injections to Brandt's neck and upper back and remarked that “a workup for counseling [was] in order.” [Tr. 1034, 1037]

         Mogilevksi referred Brandt to neurophysiologist Toufic Fakhoury, M.D, for an alleged seizure disorder in June 2017. [Tr. 975] Brandt advised Fakhoury that she experienced recurrent “spells” in which she would “zone out” and become unresponsive. Fakhoury admitted Brandt to a hospital for three days during which he performed testing to determine the cause of the alleged episodes. [Tr. 976] Brandt experienced one “spell” during the three days of testing, during which a concomitant EEG showed no change. At some point during testing, there was an indication of focal cerebral dysfunction in the temporal region. However, Fakhoury concluded that Brandt's spells likely were caused by anxiety or PTSD. Fakhoury advised Brandt to avoid driving and to follow up with Dr. Mogilevksi in six to eight weeks. [Tr. 977]

         Brandt established care with Nikola Mihaylov, M.D., in September 2017, as a new primary care provider. At that time, Brandt complained of depression, a seizure disorder, and diffuse body pain. [Tr. 1450] Mihaylov noted that Brandt's “polypharmacy [was] difficult to comprehend as many of [the] medications interact and cause significant problems with fatigue, paresthesias, dizziness, etc.” Mihaylov discussed this with Brandt, but she was “very defensive about the medication she [was] taking.” Mihaylov discontinued several medications and advised Brandt to consider decreasing the amount of medicine she was ingesting “through slow titration.” [Tr. 1451-53]

         Dr. Mihaylov referred Brandt to Ziad Sara, M.D., of Bluegrass Renal Care, in November 2017. [Tr. 1090] Brandt apparently required renal care based on abnormal lab results, but she denied any uremic symptoms. Sara concluded that Brandt had stage III chronic kidney disease due to excessive use of analgesics. He noted that Brandt's renal function had improved since prior lab work, but he counseled her to avoid using NSAIDs. Sara encouraged “routine health surveillance” and directed her to return to him in four months. [Tr. 1092]

         Dr. Mogilevski provided a medical source statement on October 16, 2017. The checklist-style form indicated that Brandt suffered “complex partial seizures” several times per week, despite her excellent compliance with treatment. [Tr. 1086] Mogilevski further reported that Brandt experienced no significant side effects from medication and that she was “unable to work.” [Tr. 1087] The ALJ gave Mogilevski's opinion “little weight” because she concluded that it was not supported by the record.

         Brandt experienced anxiety and depression following her son's death in October 2014. She began psychotherapy with Melinda Moore, Ph.D., in April 2015. [Tr. 662] Moore diagnosed acute PTSD and moderate, recurrent major depressive disorder. Counseling sessions included psychoeducation regarding suicide, processing grief, and sleep hygiene. [Tr. 664] By June 2015, Brandt appeared less dysphoric, but was still fatigued and depressed, ...


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