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Benson v. Berryhill

United States District Court, N.D. Alabama, Northwestern Division

September 22, 2017

CORD LEE BENSON, Plaintiff,
v.
NANCY BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          MEMORANDUM OPINION

          MADELINE HUGHES HAIKALA, UNITED STATES DISTRICT JUDGE

         Pursuant to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff Cord Lee Benson seeks judicial review of a final adverse decision of the Commissioner of Social Security. The Commissioner denied Mr. Benson's claims for a period of disability, disability insurance benefits, and supplemental security income. After careful review, the Court affirms the Commissioner's decision.[1]

         I. PROCEDURAL HISTORY

         Mr. Benson applied for a period of disability and disability insurance benefits and supplemental security income on January 23, 2012. (Doc. 7-4, pp. 2-3). Mr. Benson alleges that his disability began on June 10, 2009. (Doc. 7-6, pp. 2, 8). The Commissioner initially denied Mr. Benson's claims on May 7, 2012. (Doc. 7-5, pp. 2, 7). Mr. Benson requested a hearing before an Administrative Law Judge (ALJ). (Doc. 7-5, pp. 16-17). The ALJ issued an unfavorable decision on April 22, 2014. (Doc. 7-3, pp. 43-58). On February 25, 2016, the Appeals Council declined Mr. Benson's request for review (Doc. 7-3, p. 2), making the Commissioner's decision final and a proper candidate for this Court's judicial review. See 42 U.S.C. §§ 405(g) and 1383(c).

         II. STANDARD OF REVIEW

         The scope of review in this matter is limited. “When, as in this case, the ALJ denies benefits and the Appeals Council denies review, ” the Court “review[s] the ALJ's ‘factual findings with deference' and [his] ‘legal conclusions with close scrutiny.'” Riggs v. Comm'r of Soc. Sec., 522 Fed.Appx. 509, 510-11 (11th Cir. 2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).

         The Court must determine whether there is substantial evidence in the record to support the ALJ's factual findings. “Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). In evaluating the administrative record, the Court may not “decide the facts anew, reweigh the evidence, ” or substitute its judgment for that of the ALJ. Winschel v. Comm'r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal quotations and citation omitted). If substantial evidence supports the ALJ's factual findings, then the Court “must affirm even if the evidence preponderates against the Commissioner's findings.” Costigan v. Comm'r, Soc. Sec. Admin., 603 Fed.Appx. 783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).

         With respect to the ALJ's legal conclusions, the Court must determine whether the ALJ applied the correct legal standards. If the Court finds an error in the ALJ's application of the law, or if the Court finds that the ALJ failed to provide sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis, then the Court must reverse the ALJ's decision. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).

         III. SUMMARY OF THE ALJ'S DECISION

         To determine whether a claimant has proven that he is disabled, an ALJ follows a five-step sequential evaluation process. The ALJ considers:

(1) whether the claimant is currently engaged in substantial gainful activity; (2) whether the claimant has a severe impairment or combination of impairments; (3) whether the impairment meets or equals the severity of the specified impairments in the Listing of Impairments; (4) based on a residual functional capacity (“RFC”) assessment, whether the claimant can perform any of his or her past relevant work despite the impairment; and (5) whether there are significant numbers of jobs in the national economy that the claimant can perform given the claimant's RFC, age, education, and work experience.

Winschel, 631 F.3d at 1178.

         In this case, the ALJ found that Mr. Benson has not engaged in substantial gainful activity since June 15, 2009, the alleged onset date. (Doc. 7-3, p. 45).[2] The ALJ determined that Mr. Benson suffers from the following severe impairments: degenerative disc disease, degenerative joint disease with chronic low back pain/lumbago, spondylosis, sacroiliitis, osteoarthritis at multiple sites with musculoskeletal pain, arthralgias, hepatitis, coronary arterial disease, history of venous insufficiency, gout diagnosed on one occasion, episode of acute bronchitis, obesity, and depression/mood disorder. (Doc. 7-3, p. 45). Mr. Benson also has the non-severe impairment of hyperlipidemia. (Doc. 7-3, p. 46). Based on a review of the medical evidence, the ALJ concluded that Mr. Benson does not have an impairment or combination of impairments that meets or medically equals the severity of any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 7-3, p. 46).

         In light of Mr. Benson's impairments, the ALJ evaluated Mr. Benson's residual functional capacity. The ALJ determined that Mr. Benson has the RFC to perform:

light work as defined in 20 CFR 404.1567(b) and 416.967(b) except for the following limitations: the claimant can interact appropriately with supervisors but this should be casual non-confrontational and with supportive feedback; can interact appropriately with coworkers, customers, and members of the general public but this should be casual non-confrontational and infrequent; can respond appropriately to work pressures in usual work setting; can respond appropriately to changes in a routine work setting but changes should be infrequent and gradually introduced; can use judgment for simple 1-2 step work related decisions; cannot use judgment in detailed or complex work related decisions; can understand, remember, carry out simple 1-2 step instructions; cannot understand remember and carry out detailed or complex instructions; and can maintain attention, concentration and pace for at least 2 hours and concentrate and persist at tasks at an appropriate pace throughout an 8 hour day with customary work breaks. In addition, the claimant can occasionally lift and/or carry 20 pounds, and frequently up to 10 pounds. He can stand and/or walk with normal breaks for a total of 3 hours, and sit with normal breaks for a total of more than 6 hours on a sustained basis in an 8 hour workday. The claimant is limited in the bilateral lower extremities to occasional pushing and/or pulling. The claimant can occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl, but never climb[] ladders, ropes, or scaffolds. The claimant has no manipulative limitations, visual limitations, or communicative limitations. The claimant should avoid concentrated exposure to extreme cold. He is unlimited in exposure to extreme heat, wetness, humidity, noise, fumes, odors, dusts, gases, poor ventilation, etc. He should avoid concentrated exposure to vibration, and all exposure to hazards. He must avoid all unprotected heights and hazardous machinery. . . . In addition, out of an abundance of caution and giving the claimant the benefit of all doubt, the claimant will require a sit/stand option all day at the claimant's option.

(Doc. 7-3, pp. 48-49) (internal citation omitted).

         Based on this RFC, the ALJ concluded that Mr. Benson is not able to perform his past relevant work as a sand blaster, machine packager, cook/kitchen manager, or truss builder. (Doc. 7-3, p. 56). Relying on testimony from a vocational expert, the ALJ found that jobs exist in the national economy that Mr. Benson can perform, including assembler, hand packer, and call out wire worker. (Doc. 7-3, p. 57). Accordingly, the ALJ determined that Mr. Benson has not been under a disability within the meaning of the Social Security Act. (Doc. 7-3, p. 57).

         IV. SUMMARY OF THE MEDICAL EVIDENCE

         A. Record Before the ALJ

         1. Treatment Records

         On March 9, 2006, Dr. Michael Herndon at Alexandria Medical Clinic diagnosed Mr. Benson with varicose veins and leg pain and noted that Mr. Benson was obese. (Doc. 7-9, p. 28). On September 4, 2009, Dr. Herndon diagnosed Mr. Benson with acute gouty arthritis. (Doc. 7-9, p. 24). On January 7, 2010, Mr. Benson asked Dr. Herndon to refer him to a vascular surgeon. (Doc. 7-9, p. 23). During this visit, Dr. Herndon diagnosed varicose veins on Mr. Benson's legs and noted that Mr. Benson was obese. (Doc. 7-9, p. 23).

         On May 24, 2010, Mr. Benson visited the emergency room at Northeast Alabama Regional Medical Center and complained about an abscess located on his lower back. (Doc. 7-9, p. 60). Mr. Benson rated the pain a 5 out of 10. (Doc. 7-9, p. 60). Mr. Benson had a normal range of motion in his extremities. (Doc. 7-9, p. 61). Mr. Benson returned twice over the next three days for rechecks of the abscess. (Doc. 7-9, pp. 54-59). During both of these visits, Mr. Benson's musculoskeletal exams were normal. (Doc. 7-9, pp. 55, 58).

         On November 8, 2011, Mr. Benson visited Northeast Alabama Regional Medical Center after experiencing chest pain that he rated an 8 out of 10. (Doc. 7-9, p. 37). When he was admitted, Mr. Benson was not experiencing “specific discomfort, ” and doctors explained that he did “not appear to be in any pain” and did “not appear to be hurting” or experiencing distress. (Doc. 7-9, p. 37). Mr. Benson's cardiac examination was normal. Doctors noted that his extremities had no cyanosis or swelling. Mr. Benson moved all of his extremities “without any difficulty, ” and he had no erythema or swelling in his joints. (Doc. 7-9, p. 38). At discharge, Dr. Davisson Edmond diagnosed Mr. Benson with hypertension, hyperlipidemia, and chest pain. (Doc. 7-9, p. 35). Dr. Edmond noted that Mr. Benson was morbidly obese but was “ambulating very well.” (Doc. 7-9, p. 35). Mr. Benson had a negative EKG and stress test, and the rest of his physical exam was unremarkable. (Doc. 7-9, p. 35).

         On February 1, 2012, Mr. Benson saw nurse practitioner Janice Parker at Quality of Life Heatlh Services. Mr. Benson complained of lower back pain that radiated to his right thigh. (Doc. 7-10, p. 4). He stated that his symptoms were aggravated by “ascending stairs, bending, changing positions, descending stairs, lifting, sitting[, ] and walking.” (Doc. 7-10, p. 4). Although doctors had diagnosed degenerative disc disease five or six years earlier, Mr. Benson told the nurse practitioner that he had not had back problems in years. (Doc. 7-10, p. 4). Mr. Benson had no cervical spine tenderness or thoracic spine tenderness, and he had normal mobility and curvature. (Doc. 7-10, p. 6). Mr. Benson's hips had a full range of motion, and he had no joint deformity, heat, swelling, erythema, or effusion. (Doc. 7-10, p. 6). Ms. Parker noted that Mr. Benson had a reduced range of motion due to the severity of the pain radiating down the right thigh on movement and palpitation of the lumbar spine area. (Doc. 7-10, p. 6). Ms. Parker also noted Mr. Benson's lumbar spine had severe pain with motion and spasms. (Doc. 7-10, p. 6). Ms. Parker diagnosed Mr. Benson with an acute sprain in his lumbar region and acute pain in the limb. (Doc. 7-10, p. 6). She prescribed warm compresses, topical pain cream, and prescription pain medication. (Doc. 7-10, p. 6).

         On February 8, 2012, Mr. Benson saw Ms. Parker at Quality of Life again. (Doc. 7-10, p. 8). Mr. Benson complained of persistent low back pain and told Ms. Parker that his prescribed medications did not provide “much relief.” (Doc. 7-10, p. 8). Mr. Benson was positive for back pain, joint pain, and muscle weakness, and his gait was limp. (Doc. 7-10, pp. 9-10). A cervical and thoracic spine examination was normal, but Mr. Benson's lumbar spine was tender and his range of motion was moderately reduced. (Doc. 7-10, p. 10). Ms. Parker recommended an MRI of Mr. Benson's lumbar spine, and treatment notes indicate Mr. Benson was going to consider the procedure. (Doc. 7-10, p. 10).[3] Ms. Parker diagnosed chronic lumbago and chronic neuralgia, and she prescribed oral prescriptions, topical pain medication, and warm compresses. (Doc. 7-10, p. 10).

         On February 15, 2012, Mr. Benson saw Dr. Carla Thomas at Quality of Life. (Doc. 7-10, p. 12). He again complained of pain in his lower back and gluteal area. (Doc. 7-10, p. 12). The pain radiated to the left and right ankle, and Mr. Benson described the pain as “burning, deep, diffuse, and shooting.” (Doc. 7-10, p. 12). The pain was aggravated by bending, flexing, and sneezing. (Doc. 7-10, p. 12). Dr. Thomas noted that Mr. Benson's symptoms were “relieved by heat.” (Doc. 7-10, p. 12). Dr. Thomas found that Mr. Benson's left and right hips were tender, and his lumbar spine had a muscle spasm; however, Mr. Benson's gait was normal, and he had full range of motion in his extremities and an otherwise normal musculoskeletal exam. (Doc. 7-10, p. 14). Dr. Thomas explained that Mr. Benson's neuralgia and lumbar sprain had improved, and she encouraged Mr. Benson to exercise. (Doc. 7-10, p. 14).

         On February 23, 2012, Mr. Benson saw Dr. Jeffrey Pierson at Stringfellow Memorial Hospital and complained of pain in the lower back, right gluteus, and right hip after he tripped and fell. (Doc. 7-9, p. 71). Mr. Benson stated that his symptoms were of “moderate intensity.” (Doc. 7-9, p. 71). Mr. Benson was positive for extremity pain, back pain, joint pain, and myalgias. (Doc. 7-9, p. 71). Mr. Benson had severe tenderness to palpation in his mid-lumbar area. (Doc. 7-9, p. 72). Mr. Benson had mild tenderness to palpitation in the hip, but his range of motion was normal. (Doc. 7-9, p. 72). A lumbar spine x-ray showed no acute fracture. Dr. Stringfellow diagnosed Mr. Benson with an acute lumbar strain and prescribed pain medication. (Doc. 7-9, p. 72).

         On March 9, 2012, Mr. Benson saw Dr. Emanuel Joseph at Quality of Life and complained of worsening symptoms from his fall. (Doc. 7-10, p. 16). Mr. Benson described the pain as “an ache, burning, deep, piercing, shooting, stabbing, and throbbing.” (Doc. 7-10, p. 16). The symptoms were aggravated by resting, rolling over in bed, standing, twisting, and walking. (Doc. 7-10, p. 16). He could not lie on the affected side, and according to Mr. Benson, his back was acutely painful to the touch. (Doc. 7-10, p. 16). Dr. Joseph noted normal mobility and curvature in Mr. Benson's cervical and thoracic spine, but he found that Mr. Benson had antalgic gait on the right side, and Mr. Benson's lumbar spine had a muscle spasm and severe pain with motion. (Doc. 7-10, p. 17). Dr. Joseph diagnosed acute lumbago and acute bursitis and prescribed pain medication. (Doc. 7-10, p. 17).

         On March 23, 2012, Mr. Benson returned to Dr. Joseph at Quality of Life and complained that there was no improvement since his last visit and that the medication had no effect on his pain. (Doc. 7-10, p. 19). Mr. Benson stated that he experienced “sharp low back pain after sneezing” that radiated down his left thigh and leg. (Doc. 7-10, p. 19). Dr. Joseph noted that Mr. Benson was positive for back pain and that his lumbar spine was tender and had a significantly reduced range of motion. (Doc. 7-10, p. 20). Mr. Benson was negative for joint pain, joint swelling, muscle weakness, and neck pain. (Doc. 7-10, p. 20). Dr. Joseph noted normal mobility and curvature in Mr. Benson's cervical and thoracic spine. (Doc. 7-10, p. 20). Dr. Joseph commented that Mr. Benson had “antalgic gait, no weight bearing on right leg[, and] truncal tilt.” (Doc. 7-10, p. 20). Dr. Joseph diagnosed chronic lumbago, chronic lumbar sprain or strain, and bursitis. (Doc. 7-10, p. 21). He scheduled an MRI of Mr. Benson's spine and refilled Mr. Benson's medication. (Doc. 7-10, p. 21).

         On October 9, 2012, Mr. Benson saw Dr. Thomas at Quality of Life to follow up on his back and leg pain and arthalgias located in his wrist. (Doc. 7-12, p. 42). Mr. Benson was positive for decreased mobility, limping, and spasms but negative for joint instability, joint locking, joint tenderness, popping, and weakness. (Doc. 7-12, p. 43). Mr. Benson had a mildly reduced range of motion in his left knee, but otherwise, he had a normal musculoskeletal examination, and he had no other joint problems. (Doc. 7-12, p. 45). Dr. Thomas noted that Mr. Benson's hyperlipidemia, hepatitis C, and osteoarthrosis had improved, and she prescribed medication to treat Mr. Benson's symptoms and encouraged him to exercise. (Doc. 7-12, pp. 45-46).

         On November 9, 2012, Mr. Benson again visited Dr. Thomas at Quality of Life and complained of lower back and leg pain that radiated to the left ankle. (Doc. 7-12, p. 47). Mr. Benson described the pain as “diffuse and shooting.” (Doc. 7-12, p. 47). Dr. Thomas stated that Mr. Benson's symptoms were relieved by heat. (Doc. 7-12, p. 47). He had no edema in his extremities, but his gait was compensated, and his lumbar spine had a muscle spasm and a mildly reduced range of motion. (Doc. 7-12, p. 50). Again, Dr. Thomas found that Mr. Benson's hyperlipidemia, hepatitis C, and osteoarthrosis had improved. (Doc. 7-12, p. 50). She prescribed medication and encouraged aerobic exercises. (Doc. 7-12, p. 50).

         On January 3, 2013, Mr. Benson visited the Calhoun-Cleburne Mental Health Board. (Doc. 7-10, pp. 32-33). Dr. Maurice Jeter, Jr. performed a psychiatric evaluation of Mr. Benson. Dr. Jeter found that Mr. Benson was in no apparent distress, he maintained good eye contact, and he responded to questions appropriately. (Doc. 7-10, pp. 32-33). Dr. Jeter noted that Mr. Benson had “psychomotor retardation” and a depressed mood; however, Mr. Benson's affect was congruent, his insight and judgment were good, and he expressed no suicidal/homicidal ideations or psychosis. (Doc. 7-10, p. 33). Dr. Jeter diagnosed Mr. Benson with mood disorder due to chronic pain. Dr. Jeter assessed a GAF score of 60. (Doc. 7-10, p. 33). Dr. Jeter's report concludes with the following recommendations:

Patient appears to be depressed today. As well he is not sleeping well. There are significant financial stressors in his family. Will prescribe Celexa 20 mg a day and Trazodone 100mg 1/2 to 1 at night as needed for insomnia.
Patient was counseled on risks and benefits of medications, expressed understanding and consented to treatment. A safety plan was reviewed.
Patient is to follow up according to therapist recommendations.

(Doc. 7-10, p. 33)

         During an individual therapy session with a Calhoun-Cleburne Mental Health Board therapist on January 4, 2013, Mr. Benson's cognition was appropriate to the situation, and his speech was appropriate. (Doc. 7-10, p. 36). Mr. Benson arrived in a “dysphoric mood” and reported “difficulty since his wife lost her job due to lack of work.” (Doc. 7-10, p. 36). Mr. Benson reported that he had tried to keep himself “occupied” by “tak[ing] apart and pu[ting] together many things in the house.” (Doc. 7-10, p. 36). The therapist noted that Mr. Benson still had trouble sleeping, but the therapist hoped that medication would help. (Doc. 7- 10, p. 36). The therapist noted ...


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