United States District Court, W.D. Arkansas, Fort Smith Division
DALE D. REEVES PLAINTIFF
NANCY A. BERRYHILL, Acting Commissioner, Social Security Administration DEFENDANT
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
Dale D. Reeves, brings this action pursuant to 42 U.S.C.
§ 405(g), seeking judicial review of a decision of the
Commissioner of the Social Security Administration
(Commissioner) denying his claim for a period of disability
and disability insurance benefits (DIB) under the provisions
of Title II of the Social Security Act (Act). In this
judicial review, the Court must determine whether there is
substantial evidence in the administrative record to support
the Commissioner's decision. See 42 U.S.C.
protectively filed his current application for DIB on January
9, 2015, alleging an inability to work since February 21,
2014, due to degenerative disc disease and bipolar disorder.
(Tr. 76, 90). For DIB purposes, Plaintiff maintained insured
status through December 31, 2019. (Tr. 76, 90). An
administrative hearing was held on May 24, 2016, at which
Plaintiff appeared with counsel and testified. (Tr. 44-74).
Deborah Steele, Vocational Expert (VE) also testified. (Tr.
written opinion dated July 27, 2016, the ALJ found that the
Plaintiff had a severe impairment of degenerative disc
disease. (Tr. 32). However, after reviewing the evidence in
its entirety, the ALJ determined that the Plaintiff's
impairments did not meet or equal the level of severity of
any listed impairments described in Appendix 1 of the
Regulations (20 CFR, Subpart P, Appendix 1). (Tr. 34). The
ALJ found Plaintiff retained the residual functional capacity
(RFC) to perform light work, except that Plaintiff could
occasionally stoop, crouch, kneel, climb and crawl. (Tr.
35-37). With the help of VE testimony, the ALJ determined
that Plaintiff was unable to perform his past relevant work
as a molder, molding and trim installer, automotive worker,
automotive detailer, and car wash supervisor. (Tr. 37).
However, based on the Plaintiff's age, education, work
experience, and RFC, the ALJ determined that Plaintiff was
capable of work as a bottling line attendant, a bindery
machine feeder, and a plastic hospital products assembler.
(Tr. 38). Ultimately, the ALJ concluded that the Plaintiff
had not been under a disability within the meaning of the
Social Security Act from February 21, 2014, through the date
of the decision. (Tr. 38).
Plaintiff requested a review of the hearing decision by the
Appeals Council, which after reviewing additional evidence
submitted by the Plaintiff, denied that request on August 25,
2017. (Tr. 1-6). Plaintiff filed a Petition for Judicial
Review of the matter on October 5, 2017. (Doc. 1). Both
parties have submitted briefs, and this case is before the
undersigned for report and recommendation. (Docs. 14, 15).
Court has reviewed the transcript in its entirety. The
complete set of facts and arguments are presented in the
parties' briefs and are repeated here only to the extent
hearing before the ALJ on May 24, 2016, Plaintiff testified
that he was born in 1964 and had obtained his GED. (Tr. 47).
Plaintiff's past relevant work consisted of work as a
molder, a molding and trim installer, an automotive worker,
an automobile detailer, and a car wash supervisor. (Tr. 63).
to the relevant time period, from August 28, 2007, through
January 30, 2008, Plaintiff was treated for anger issues by
Dr. Richard Barrett, II, Ph.D. (Tr. 525-527, 529-530,
536-546). On October 29, 2007, Dr. Barrett, authored a
letter, stating that Plaintiff was experiencing symptoms
consistent with bipolar disorder with episodic psychotic
features. (Tr. 524). Dr. Barrett recommended a mood
stabilizer and that Plaintiff follow up with a psychiatrist.
(Tr. 524). Moreover, between May of 2013 and January of 2014,
Plaintiff was treated conservatively for low back pain and
was diagnosed with an umbilical hernia. (Tr. 278-279,
296-297, 348, 350-351, 387, 397, 414, 418, 435, 452-453).
evidence during the relevant time period reflects that on
March 31, 2014, Plaintiff visited UAMS Family Medical Center
Fort Smith to establish care and with complaints of a ventral
hernia. (Tr. 310). Dr. Lyndsey Kramp referred Plaintiff to
surgery for the hernia. (Tr. 313).
April 23, 2014, Plaintiff presented at Mercy Surgery and
Gastroenterology Clinic with complaints of an umbilical
hernia. (Tr. 282). Dr. Nabil Akkad opined that Plaintiff
would benefit from hernia repair with mesh placement. (Tr.
283). On that same date, Plaintiff also visited Arkansas
Surgical Group, where Plaintiff was scheduled for surgery and
pre-operative instructions were given. (Tr. 343-344).
3, 2014, Plaintiff underwent an open repair of his umbilical
ventral hernia. (Tr. 317).
17, 2014, Plaintiff visited Arkansas Surgical Group for a
follow up from surgery. (Tr. 341). Plaintiff reported that he
was doing well with minimal abdominal soreness, and he denied
fever, chills, and pain. (Tr. 341). Plaintiff was instructed
to keep the incision clean and dry and to notify the clinic
of any problems. (Tr. 342).
August 7, 2014, Plaintiff returned to Arkansas Surgical Group
for a follow up from surgery. (Tr. 339). Plaintiff was
ordered to continue to follow lifting restrictions and that
no further follow up was necessary. (Tr. 340).
September 3, 2014, imaging of Plaintiff's lumbar spine
showed mild disc space narrowing at ¶ 4-5, marked disc
space narrowing at ¶ 5-S1 compatible with degenerative
disc disease, and degenerative facet changes in the lower
lumbar segments. (Tr. 323). Plaintiff also visited UAMS
Family Medical Center that day for low back pain. (Tr. 590).
Clinic notes indicated that a lumbar x-ray would be ordered
and that Plaintiff would start conservative management. (Tr.
September 9, 2014, Plaintiff returned to UAMS Family Medical
Center in Fort Smith with complaints of low back pain. (Tr.
319). Upon examination, Plaintiff had normal gait and
station, no hot, red, or tender joints, and no obvious
deformities, dislocation or fracture. (Tr. 320). Clinic notes
indicated that Plaintiff would begin conservative treatment,
including heat, medication, modified activity,
stretching/strengthening exercises, and would have a repeat
x-ray of his lumbar spine. (Tr. 321).
September 22, 2014, Plaintiff had a follow up visit at UAMS
Family Medical Center in Fort Smith for back pain. Plaintiff
reported that conservative treatment had not offered much
relief and that his pain was impacting his job. (Tr. 324).
Upon physical examination, Plaintiff had normal gait and
station, no tenderness in his joints, and no obvious
deformity, dislocation or fracture. (Tr. 325). Plaintiff had
some positive findings on his lumbar exam and a MRI was
ordered. He was assessed with degenerative disc disease,
lumbar spine, and his medication was altered. (Tr. 326).
October 6, 2014, Plaintiff presented at UAMS Family Medical
Center in Fort Smith for a follow up visit for his back pain.
(Tr. 328). A re-order was made for a MRI on Plaintiff's
spine. (Tr. 330).
November 20, 2014, Plaintiff presented at UAMS Family Medical
Center in Fort Smith for a follow up visit for his back pain.
(Tr. 331). Dr. Tabasum Imran recommended that Plaintiff
continue to limit activity, continue heat or ice on his back,
take his medication as instructed, and start physical
therapy. (Tr. 334). Clinic notes indicated that “(90%)
of patients with low back pain will improve with time (2-6
weeks).” (Tr. 334).
December 4, 2014, Plaintiff saw Dr. Thomas Cheyne for chronic
low back pain, bilateral hip and bilateral thigh pain and
numbness, which was worse on the right than the left. (Tr.
290). Plaintiff reported having undergone physical therapy
and had taken naproxen and ibuprofen for weeks with no
relief. (Tr. 290). Upon examination, Plaintiff's gait was
normal; he had normal strength and muscle tone in his arms;
he could walk on toes and heels without difficulty; he had
good strength and muscle tone in his legs; his straight-leg
raise was negative bilaterally; and he had full range of
motion and no pain in his hips, knees, and ankles. (Tr. 289).
Dr. Cheyne determined that Plaintiff had chronic sciatica
bilaterally with underlying severe degenerative disc disease
at ¶ 5-S1. (Tr. 289). Dr. Cheyne instructed him to take
Mobic, stay at light activity, and use heat twice a day. He
also ordered a MRI on his lumbar spine. (Tr. 289). An x-ray
of Plaintiff's lumbar spine on that day showed severe
degenerative disc disease at ¶ 5-S1, but was otherwise
unremarkable. (Tr. 291). Plaintiff also underwent an x-ray of
his pelvis that day, which yielded normal results. (Tr. 293).
January 13, 2015, patient appointment list showed that
Plaintiff received physical therapy on the following dates:
November 24, 2014, December 1, 2014, December 3, 2014,
December 5, 2014, December 8, 2014, December 10, 2014,
December 12, 2014, December 15, 2014, December 17, ...