Goolsby v. Social Security Administration Commissioner

          MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

          HON. ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE

         Plaintiff, David Goolsby Jr., 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 claims 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. § 405(g).

         I. Procedural Background:

         Plaintiff protectively filed his current application for DIB on May 10, 2016, alleging an inability to work since April 1, 2011, ^[1] due to degenerative disc disease of the cervical and lumbar spine, rheumatoid arthritis, high blood pressure, a bulging disc, and numbness of the hand and right shoulder. (Tr. 59). For DIB purposes, Plaintiff maintained insured status through December 31, 2016. (Tr. 10, 170). An administrative hearing was held on June 1, 2017, at which Plaintiff appeared with counsel and testified. (Tr. 24-56).

         By written decision dated August 9, 2017, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 12). Specifically, the ALJ found that through the date last insured Plaintiff had the following severe impairments: degenerative disc disease of the lumbar spine (L3-4, L4-5, L5-S1); degenerative disc disease of the cervical spine (status post fusion C3-4, C4-5, C5-6, C6-7); degenerative joint disease of the left elbow; and anxiety. However, after reviewing all of the evidence presented, the ALJ determined that through the date last insured Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 12). The ALJ found that through the date last insured Plaintiff retained the residual functional capacity (RFC) to:

perform light work as defined in 20 CFR 404.1567(b) except simple tasks, simple instructions, and incidental contact with the public.

(Tr. 14). With the help of a vocational expert, the ALJ determined that through the date last insured, Plaintiff could perform work as a palletizer, a machine egg washer, a housekeeping cleaner, and a toll collector. (Tr. 17).

         Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on March 14, 2018. (Tr. 1-6). Subsequently, Plaintiff filed this action. (Doc. 1). Both parties have filed appeal briefs, and the case is before the undersigned for report and recommendation. (Docs. 16, 17).

         The Court has reviewed the entire transcript. The complete set of facts and arguments are presented in the parties' briefs, and are repeated here only to the extent necessary.

         II. Evidence Presented:

         At an administrative hearing held before the ALJ on June 1, 2017, Plaintiff, who was forty-eight years of age, testified that he obtained a high school education. (Tr. 30-31). The record reflects Plaintiff's past relevant work consists of work as a deep fry cook, a painting machine operator, a furnace mason and a brick layer. (Tr. 50).

         Prior to the relevant time period, Plaintiff was treated for various impairments to include, but not limited to neck pain, back pain, arm pain, and high blood pressure.

         The pertinent medical evidence before the ALJ during the relevant time period reflects the following. Progress notes dated December 4, 2014, revealed Plaintiff was in to discuss his cervical spine x-rays. (Tr. 370). Upon examination, Dr. William A. Isely noted Plaintiff appeared uncomfortable due to pain. Plaintiff also exhibited neck and back tenderness with decreased range of motion. Dr. Isely assessed Plaintiff with back pain and neck pain and prescribed medication.

         On January 15, 2015, Plaintiff underwent a MRI of the cervical spine that revealed congenitally shortened pedicles, multilevel disc osteophyte ridges, degenerative disc disease and spinal and foraminal stenosis most notably at ¶ 5-C6 and C6-C7. (Tr. 334).

         Progress notes dated January 15, 2015, revealed Plaintiff was in for a follow up and medication refill. (Tr. 368-369). Dr. Isely noted Plaintiff had undergone a MRI due to progressive cervical and lumbar pain. Upon examination, Dr. Isely noted Plaintiff appeared uncomfortable due to pain. Plaintiff also exhibited neck and back tenderness with decreased range of motion. Dr. Isely assessed Plaintiff with back pain, neck pain and anxious depression and prescribed medication.

         Progress noted dated February 24, 2015, revealed Plaintiff was in for medication refills. (Tr. 367-368). Treatment notes indicated Plaintiff's blood pressure was high. Plaintiff reported he was irritated and stressed. Dr. Isely noted Plaintiff would have a surgery consult in March. Upon examination, Dr. Isely noted Plaintiff appeared uncomfortable due to pain. Plaintiff also exhibited neck and back tenderness with decreased range of motion. Dr. Isely assessed Plaintiff with back pain, anxiety and depression, neck pain and chronic pain and prescribed medication.

         Progress notes dated April 15, 2015, revealed Plaintiff was in for medication refills. (Tr. 366-367). Treatment notes indicated Plaintiff had an upcoming appointment with a surgeon. Plaintiff was examined and assessed with chronic pain, anxiety, degenerative joint disease, back pain and neck pain. Dr. Isely refilled Plaintiff's medications.

         On April 30 2015, Plaintiff was seen for a consultation regarding cervical radiculopathy. (Tr. 483-485). Plaintiff reported that his neck pain was made worse with neck movement. Plaintiff also reported upper extremity weakness and numbness. After examining Plaintiff, Candace Harper, P.A., assessed Plaintiff with cervical spine degeneration and cervical spinal stenosis. Ms. Harper noted that she would review Plaintiff's treatment plan with a surgeon.

         Progress notes dated May 12, 2015, revealed Plaintiff was seen to discuss an upcoming surgery and to receive medication refills. (Tr. 364-365). Plaintiff was examined and assessed with chronic pain, neck pain, degenerative joint disease and back pain. Dr. Isely refilled Plaintiff's medications.

         Progress notes dated June 12, 2015, revealed Plaintiff was having trouble with his prostate and urinating. (Tr. 362-364). Plaintiff reported his neurology appointment had been postponed for two weeks. Upon examination, Dr. Isely noted Plaintiff appeared uncomfortable due to pain. Plaintiff also exhibited neck and back tenderness with decreased range of motion. Dr. Isely assessed Plaintiff with urinary retention due to benign prostatic hyperplasia, chronic pain, prostatitis, neck pain and back pain and prescribed medication.

         On July 1, 2015, Dr. Larry Armstrong noted that Plaintiff was initially seen for a cervical spine physical therapy evaluation. (Tr. 470-472). Plaintiff reported increased difficulty with his upper extremities which included dropping items and experiencing episodic weakness. Dr. Armstrong noted that conservative treatment had failed to improve Plaintiff's symptoms and he recommend surgical repair.

         Progress notes dated August 27, 2015, revealed Plaintiff was seen for continuing pain and medication refills. (Tr. 361-362). Upon examination, Dr. Isely noted Plaintiff exhibited neck and back tenderness with decreased range of motion. Dr. Isely assessed Plaintiff with chronic pain, back pain, degenerative joint disease, neck pain, anxiety and hypertension and prescribed medication.

         Progress notes dated September 29, 2015, revealed Plaintiff's complaints of head and chest congestion. (Tr. 360-361). Treatment notes indicated Plaintiff would see a neurologist in two weeks. Upon examination, Dr. Isely noted Plaintiff appeared uncomfortable due to pain. Plaintiff also exhibited congestion and neck and back tenderness. Dr. Isely assessed Plaintiff with chronic pain and sinusitis and prescribed medication.

         On October 8, 2015, Plaintiff underwent an Anterior Cervical Discectomy and Fusion (ACDF) at ¶ 5-7, performed by Dr. ...