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Vaughn v. Berryhill

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

December 9, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Michael E. Vaughan (“Plaintiff” or “Vaughan”) brings this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security (“Commissioner”) to deny his claim for disability insurance benefits (“DIB”) and Supplemental Security Income (“SSI”). See 42 U.S.C. §§405(g) and 1383(c). After careful review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be affirmed.

         I. Proceedings Below

         Plaintiff filed applications for DIB and SSI on April 10, 2015, and March 15, 2016, respectively. (Tr. 49, 136, 249). Plaintiff alleged disability beginning April 10, 2012.[1] (Id.). Plaintiff's claim was initially denied on August 12, 2015. (Tr. 70). After his application was denied, Plaintiff filed a request for a hearing. (Tr. 75-76). On July 19, 2017, Plaintiff received a hearing before Administrative Law Judge (“ALJ”) Mary E. Helmer. (Tr. 29-45). On November 13, 2017, the ALJ determined that Plaintiff was not disabled under Sections 216(i), 223(d), and 1614(a)(3)(A) of the Act. (Tr. 24).

         On July 16, 2018, the Appeals Council denied Plaintiff's request for review of the ALJ's decision. (Tr. 1-3). Following that denial, the final decision of the Commissioner became a proper subject of this court's appellate review. See Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986) (finding the ALJ decision final for purposes of judicial review when the Appeals Council denied review).

         Plaintiff was forty-one years old both at the time of his hearing before the ALJ, and when the ALJ's decision was rendered. (Tr. 23, 136, 277). Plaintiff competed his GED, two years of college, and CDL school. (Tr. 175, 320). He has previously worked in the banking, lawn care, and distribution industries. (Id.). These jobs included work as a teller, landscaper, and material handler in a shipping and receiving facility. (Tr. 32, 42, 160). In the spring of 2012, Plaintiff was “let go” from his employment at a shipping and receiving facility for failing to “make production.” (Tr. 32). He has not regained employment since his dismissal in 2012. (Tr. 37). He alleges he has not been able to engage in substantial gainful employment since March 4, 2015, when he “became unable to work due to major depressive disorder with psychotic features, post-traumatic stress disorder (PTSD), panic disorder with agoraphobia, mood disorder, personality disorder, anxiety disorder, and cervical and thoracic degenerative disc disease.” (Doc. #13 at 4).

         In October 2012, Plaintiff began seeking treatment for back pain at Med-Assist Doctors Group in Albertville, Alabama. (Tr. 283-84.). He sought pain management for thoracic and lumbar back pain. (Id.). At the time, Plaintiff was taking 180 pills of Lortab 10 each month. (Id.). However, Plaintiff had never had an MRI of his spine. (Id.). As a result, his treating physician, Dr. Larry Johnston, M.D., informed him that he would not prescribe Plaintiff a pain management regiment without further imaging of his spine. (Id.).

         In February 2015, Plaintiff sought treatment at Marshall Medical Center for injuries incurred as a result of a fall. (Tr. 290). He complained of mild pain to his mid-back and right hand. (Id.). The treating physician, Dr. Lisa Driskill, M.D., noted that Plaintiff had a painless range of motion with no tenderness in his neck and a normal range of motion with mild tenderness over the mid-thoracic spine. (Tr. 291). AP, lateral, and swimmers views of the thoracic spine revealed no evidence of fractures, dislocation, or soft tissue abnormality, and Plaintiff's thoracic vertebral disc bodies and disc spaces were normal. (Id.) Plaintiff was prescribed pain medication and a muscle relaxant and was subsequently discharged. (Tr. 293).

         In March and April 2015, Plaintiff sought treatment numerous times at Care Plus Family Medical, LLC in Albertville, Alabama. (Tr. 303-05). He complained of neck and upper back pain. (Tr. 305). Plaintiff was prescribed pain medication and a muscle relaxant. (Tr. 306). Plaintiff subsequently sought referral to an orthopedic specialist. (Tr. 303).

         In April 2015, Plaintiff was treated at the Orthopaedic Center, P.C. by Dr. Vandana Maladkar, M.D., for neck and back pain. (Tr. 311). After examination, Dr. Maladkar diagnosed Plaintiff with neck pain with bilateral arm pain and thoracic pain radiating into his chest wall. (Tr. 312). Subsequent test results and MRI imaging revealed that he did have “some straightening of the cervical spine and minimal degenerative changes noted with mild disc desiccation.” (Tr. 310). Further, Dr. Maladkar noted that there was “some mild osteophytes and facet hypertrophy consistent with arthritis.” (Id.). Dr. Maladkar discussed treatment options with Plaintiff including “anti-inflammatory, physical therapy and epidurals.” (Id.). Plaintiff stated that he would think about his treatment options and that he would like something for pain in the meantime; however, Dr. Maladkar responded that he does not prescribe pain management, but he could refer Plaintiff to a pain clinic if pain was an issue. (Tr. 310).

         In July 2015, Plaintiff underwent a psychological evaluation, which was performed by Dr. Mary Arnold, Psy.D. (Tr. 318-19). Plaintiff told Dr. Arnold that he started a pain management methadone program on April 20, 2015 which requires a daily commute to Huntsville, Alabama. (Id.). Dr. Arnold noted that Plaintiff had a lengthy history of substance abuse including use of Demerol, oxycodone, oxytocin, dilaudid, heroin, and methamphetamine. (Tr. 320). Dr. Arnold also noted Plaintiff's visits to Dr. Lachman, a psychiatrist; however, no admission to a psychiatric unit had been reported. (Id.). Further, Dr. Arnold also noted that he displayed “no overt indicator of pain or impairment” and that he was “passively compliant and his demeanor [was] mellow.” (Id.). After several cognition, information, thought processing, abstract reasoning, and judgment tests, Dr. Arnold concluded that Plaintiff's FSIQ was “estimated to be [in the] low average range.” (Tr. 321).

         As of June 19, 2017, Plaintiff was still undergoing treatment at Huntsville Metro Treatment Center for a “chemical dependency.” (Tr. 336). This treatment requires him to receive a 220-milligram dose of methadone per day and serves to “eliminate [Plaintiff's] illicit narcotics cravings, prevents the onset of any withdrawal illness, and serves to establish a blockade effect against other narcotic use.” (Id.). As part of the program, Plaintiff meets with a counselor once a month, at a minimum, and is subjected to random mandatory drug screening. (Id.).

         On March 3, 2015, Plaintiff began being treated by Dr. Elizabeth Lachman, M.D., a psychiatrist. (Tr. 326). From March 3, 2015 to July 21, 2017, Plaintiff was evaluated eighteen times by Dr. Lachman. (Tr. 364-65). Dr. Lachman concluded that he had “a history of severe and worsening mental symptoms of serious mental illness as defined by DSM V, a further history of polysubstance abuse and is [sic] the case of many with a history of Bipolar I Disorder, and yet a further history of chronic, severe, declining occupational, social and personal functioning . . . .” (Tr. 325, 328, 364). Dr. Lachman's official diagnoses included “Major Depressive Disorder, Severe, Recurrent, With Psychotic Features . . . Post Traumatic Stress Disorder . . . Panic Disorder With Agoraphobia [and] Complicated Bereavement.” (Id.). Dr. Lachman concluded:

Mr. Michael Eric Vaughan's psychiatric symptoms led to a marked, severe, and sometimes extreme degree of impairment in all areas related to occupational functioning. Mr. Michael Eric Vaughan is unable to work an eight hour day or even a four hour day. He is unable to perform routine work. He is unable to work with colleagues appropriately and unable to take orders from supervisors. He is unable to follow even simple and certainly complex directions. He is unable to adapt to changes in the work routine or the work environment. He is unable to interact appropriately with the public.

(Tr. 327, 330, 365). Dr. Lachman determined that Plaintiff was “unsafe and not able to function in the occupational setting.” (Id.). Initially, Dr. Lachman opined that Plaintiff was unable to work for approximately 12-24 months; however, she subsequently altered the duration to that “foreseeable future.” (Id.).

         In August 2015, a non-examining state medical consultant, Dr. Teresa Moran, M.D., determined that Plaintiff was able to remember locations and work-like procedures. (Tr. 63). Dr. Moran opined that Plaintiff was also able to remember very short and simple instructions; however, Dr. Moran determined that he was unable to remember those that are longer or more complex. (Tr. 63-64). Dr. Moran determined that Plaintiff was able to maintain activities within a schedule, interact with the general public, ask simple questions or request assistance, and maintain appropriate behavior in the workplace. (Tr. 64-65). However, Dr. Moran opined that Plaintiff had moderate limitations in these areas: being distracted by others; maintaining a routine without a supervisor; concentrating for ...

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