United States District Court, W.D. Arkansas, Fort Smith Division
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.
...