Bell v. Kijakazi
| Docket Number | Civil Action 3:22-CV-01190-G-BH |
| Decision Date | 14 July 2023 |
| Parties | COREY DESHAUN BELL, Plaintiff, v. KILOLO KIJAKAZI, ACTING COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant. |
| Court | U.S. District Court — Northern District of Texas |
1
COREY DESHAUN BELL, Plaintiff,
v.
KILOLO KIJAKAZI, ACTING COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.
Civil Action No. 3:22-CV-01190-G-BH
United States District Court, N.D. Texas, Dallas Division
July 14, 2023
Referred to U.S. Magistrate Judge[1]
FINDINGS, CONCLUSIONS, AND RECOMMENDATION
IRMA CARRILLO RAMIREZ, UNITED STATES MAGISTRATE JUDGE
Based on the relevant filings, evidence, and applicable law, the final decision of the Commissioner of Social Security (Commissioner) denying the plaintiff's claim for Disability Insurance Benefits (DIB) under Title II of the Social Security Act (the Act) should be AFFIRMED.
I. BACKGROUND
Corey Deshaun Bell (Plaintiff) filed his application for DIB on June 5, 2020, alleging disability beginning January 1, 2020. (doc. 13-1 at 184.)[2] His claim was denied initially on August 3, 2020, and upon reconsideration on November 4, 2020. (Id. at 77-84, 86-97.) After requesting a hearing before an Administrative Law Judge (ALJ), he appeared and testified at a telephonic hearing on April 6, 2021, during which the ALJ granted his motion to amend his alleged onset date to March 4, 2020. (Id. at 55-76, 118.) On May 12, 2021, the ALJ found that Plaintiff had not been disabled since March 4, 2020, the date of his amended alleged onset date. (Id. at 41-50.)
Plaintiff timely appealed the ALJ's decision to the Appeals Council, which denied his request for review on February 3, 2022, making the ALJ's decision the final decision of the Commissioner. (Id. at 9-13.) He timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)
A. Age, Education, and Work Experience
Plaintiff was born on January 8, 1974; he was 46 years old on his amended alleged onset date. (doc. 13-1 at 62-64, 184.) He had at least a high school education and past relevant work as a tractor trailer truck driver. (Id. at 216, 225.)
B. Medical Evidence
In early 2020, Plaintiff was treated for low back pain due to post-laminectomy syndrome by Brian Wiley, M.D. (Pain Doctor). (Id. at 611-28.) In January 2020, Plaintiff complained of aching, constant, dull, shooting, and stabbing lower back pain at 8/10; it worsened when he stood, sat, exercised, bended, stretched, or twisted, but lying down and medication relieved it. (Id. at 62328.) He had last taken his pain medication three days earlier due to restrictions on use of narcotics while driving. (Id. at 623.) He had limited and painful range of motion in the lumbar spine, positive bilateral straight-leg raise test, positive bilateral femoral nerve traction test, positive bilateral Patrick-Fabere test, and abnormal gait and stance, but no paraspinal muscle[3] atrophy, weakness, or spasms. (Id. at 625.) He reported a history of 80 to 90 percent improvement with physical therapy and aquatic exercises. (Id. at 624.) His prescribed caudal epidural steroid injection (ESI) had been denied, but his requested physical therapy was ordered. (Id. at 628.)[4] In February 2020,
Plaintiff's complaints remained the same, but he had 5/5 strength in the bilateral upper and lower extremities. (Id. at 617-22.) In March 2020, he reported the same symptoms as well as numbness and a left-sided decrease in his ability to function, range of motion, and mobility since a prior surgery. (Id. at 611-16.) At each visit, his pain medication was refilled. (Id. at 611-28.)
Between April 2020 and August 2020, Plaintiff visited Pain Doctor for lower back pain. (Id. at 593-98, 600-10, 709-14.) At each visit, his pain medication was refilled. (Id.) In April 2020, his condition remained the same, except he had decreased sensation and pain along the L5-S1 nerve distribution, increasing numbness/tingling in his left leg with standing, and decreased strength in his left leg. (Id. at 605-10.) His caudal ESI was again reordered. (Id. at 608.) During a May 2020 telemedicine visit, Plaintiff again reported the same symptoms and limitations, except his pain had decreased to 6/10. (Id. at 600-04.) His condition remained the same in July 2020, except his pain had increased to 8/10 because he had skipped doses in order to drive. (Id. at 59398.) Plaintiff stated that because his caudal ESI had been denied by worker's compensation due to an administrative error, he would try to cover it with private insurance. (Id.) In August 2020, Plaintiff's condition remained the same, except his pain had increased to 10/10, his left lower extremity had weakness, and he was limited to part-time work because he could drive 2 days in a row before he needed to rest for 3 days. (Id. at 709-14.)[5]
On August 3, 2020, state agency medical consultant (SAMC) Cynthia Linardos, M.D., completed a physical residual functional capacity (RFC) assessment based on Plaintiff's medical record. (Id. at 77-84.) She opined that he was capable of light work, except he could occasionally note. (doc. 13-1 at 628.)
balance, stoop, kneel, crouch, crawl, and climb ramps/stairs but never climb ladders, ropes, or scaffolds. (Id. at 81-82.)
On August 5, 2020, Pain Doctor first administered a caudal ESI due to post-laminectomy syndrome. (Id. at 715-17.) At admission, Plaintiff had “[n]o limitations” with range of motion/sensation, and his pain was 1/10 throughout the procedure. (Id. at 804.) He tolerated the procedure “well” and was discharged to the recovery room; he was able to move his lower extremities and his pain improved. (Id. at 764.)
On November 4, 2020, SAMC Nancy Armstrong, M.D., also completed a physical RFC assessment based on the medical evidence of record. (Id. at 86-100.) She concurred with SAMC Linardos's findings, except she limited Plaintiff to standing and/or walking 3 hours in an 8-hour workday, and she reduced his exertional ability from light to sedentary work. (Id. at 95-96.)
On December 19, 2020, Pain Doctor completed a one-page checkbox and fill-in-the-blank physical medical source statement reflecting his diagnosis of post-laminectomy syndrome and spinal stenosis. (Id. at 818.) He opined that Plaintiff had a “questionable” prognosis, his symptoms included pain and immobility, and his pain or other symptoms would “frequently” be severe enough to interfere with his attention and concentration to perform “simple work tasks”. (Id.) The statement noted that Plaintiff was able to sit “less than 2 hours” and stand/walk “less than 2 hours” in an 8-hour day, and that he could frequently lift/carry less than 50 pounds (Id.) He would also need to take unscheduled breaks every 2 hours throughout the workdays, his breaks would last anywhere between 15 to 60 minutes, and he would miss about 3 workdays a month due to his impairments or treatments. (Id.) Pain Doctor's statement was not accompanied by any explanatory notes or supporting objective tests and examinations.
C. Psychological and Psychiatric Evidence
At his seven pain management visits between January and August 2020, Plaintiff had a Patient Health Questionnaire 9 (PHQ-9) score of 0 out of 21. (Id. at 593-98, 600-28, 709-14.) He denied nervousness, anxiety, depression, sleep disturbances, or suicidal ideation, and he had calm mood, normal affect, intact insight, and unimpaired judgment. (Id.) He had a reported history of anxiety disorder, not otherwise specified. (Id.)
At his August 2020 pain management visit, Plaintiff had normal psychosocial symptoms, specifically denied any anxiety, and was in “no distress”. (Id. at 767, 804.)
On October 19, 2020, state agency psychological consultant (SAPC) Robert Clanton, Ph.D., completed a psychiatric review technique based on Plaintiff's medical record. (Id. at 8697.) He concluded that Plaintiff had no medically determinable mental impairment. (Id. at 93.)
On February 26, 2021, Plaintiff visited Veterans Affairs for a mental health diagnostic, which was conducted by Caroline C. Ndumele, MSN, PMHNP-BC (Nurse Practitioner). (Id. at 824-831.) His PHQ-9 score was 16 out of 21, indicating moderately severe depression. (Id. at 82627.) His Generalized Anxiety Disorder 7 (GAD-7) score was 10 out of 21, indicating “moderate” anxiety. (Id. at 824-25, 829-30.) He reported a history of military service, family conflict, isolation, back surgery, and chronic back pain, and he endorsed “mod[erate]” symptoms of depression and anxiety, poor sleep, and intermittent anger and irritability, which had increased since he had stopped working, but he had no history of mental health treatment or hospitalization. (Id. at 82829.) He was reportedly told to “find another job”, but it was “not easy” after 17 years of working as a truck driver. (Id. at 829.) On mental status examination, he was calm, cooperative, and well groomed, and he had good eye contact, stable affect, average intellect, fair judgment, and intact concentration for conversation. (Id. at 830.) He recalled three of three words “at 5 min[utes]”, his
speech was normal in rate and clear with coherent thought process, and he denied any hallucinations or distress. (Id. at 830-31.) He was found to “not lack cognitive ability” to make relevant decisions and to “not have ... mental impairments that increase [his] risk of harm to self or others”. (Id. at 832.) Nurse Practitioner diagnosed him with adjustment disorder with mixed anxiety and depressed mood, and she advised him to engage in good sleep hygiene and general stress management exercises. (Id. at 831.) She found that Plaintiff “may” benefit from psychotherapy and/or pharmacotherapy, but he declined psychotropic medications. (Id.)
D. April 6, 2021 Hearing
On April 6, 2021, Plaintiff and a vocational expert (VE) both testified at a hearing before the ALJ. (Id. at 55-76.) Plaintiff was represented by an attorney. (Id.)[6]
1. Plaintiff's Testimony
Plaintiff testified that he could not work due to back pain which he rated as 9.5/10. (Id. at 66-69.) He had back surgery in 2016, and he used a back brace daily, as well as a...
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