Berry v. Saul, CIVIL ACTION NO. 3:19-cv-00259

Decision Date30 March 2020
Docket NumberCIVIL ACTION NO. 3:19-cv-00259
PartiesREAGAN LANETTE BERRY, Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
CourtU.S. District Court — Southern District of West Virginia
PROPOSED FINDINGS & RECOMMENDATION

Plaintiff Reagan Lanette Berry ("Claimant") seeks review of the final decision of the Commissioner of Social Security (the "Commissioner") denying her applications for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-33, and for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-83f. By standing order entered on January 4, 2016, and filed in this case on April 10, 2019, this matter was referred to the undersigned United States Magistrate Judge to consider the pleadings and evidence and to submit proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). (ECF No. 3.) Presently pending before this Court are Claimant's Motion for Judgment on the Pleadings and Brief in Support of Motion for Judgment on thePleadings (ECF Nos. 12, 13) and the Commissioner's Brief in Support of Defendant's Decision (ECF No. 16).

Having fully considered the record and the arguments of the parties, the undersigned respectfully RECOMMENDS that the presiding District Judge DENY Claimant's request to reverse the Commissioner's decision (ECF No. 12), GRANT the Commissioner's request to affirm his decision (ECF No. 16), AFFIRM the final decision of the Commissioner, and DISMISS this action from the Court's docket.

I. BACKGROUND
A. Information about Claimant and Procedural History of Claim

Claimant was 31 years old at the time of her alleged disability onset date and 37 years old on the date of the decision by the Administrative Law Judge ("ALJ"). (See Tr. at 289, 293.)2 She is a high school graduate. (Id. at 38-39, 326.) Most recently, she was self-employed as a babysitter, and she has also worked as a bill collector and pressed clothes at a dry cleaner. (Id. at 40-44, 314.) Claimant alleges that she became disabled on December 31, 2011, due to a heart condition, osteoarthritis, carpal tunnel syndrome, panic disorder, and agoraphobia. (Id. at 289, 293, 325.)

Claimant filed her applications for benefits on March 23, 2016. (Id. at 289-301.)3 Her claims were initially denied on May 4, 2016, and again upon reconsideration on August 3, 2016. (Id. at 180-90, 202-17.) Thereafter, on August 23, 2016, Claimant filed a written request for hearing. (Id. at 218-22.) An administrative hearing was held before an ALJ on February 21, 2018, in Huntington, West Virginia, with the ALJ appearing fromBaltimore, Maryland. (Id. at 33-67.) On March 21, 2018, the ALJ entered an unfavorable decision. (Id. at 12-32.) Claimant then sought review of the ALJ's decision by the Appeals Council on May 18, 2018. (Id. at 280-88.) The Appeals Council denied Claimant's request for review on February 14, 2019, and the ALJ's decision became the final decision of the Commissioner on that date. (Id. at 1-6.)

Claimant timely brought the present action on April 9, 2019, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2.) The Commissioner filed an Answer (ECF No. 6) and a transcript of the administrative proceedings (ECF No. 7). Claimant subsequently filed her Motion for Judgment on the Pleadings and Brief in Support of Motion for Judgment on the Pleadings (ECF Nos. 12, 13), and in response, the Commissioner filed his Brief in Support of Defendant's Decision (ECF No. 16). As such, this matter is fully briefed and ready for resolution.

B. Relevant Medical Evidence

The undersigned has considered all evidence of record, including the medical evidence, pertaining to Claimant's arguments and summarizes it here for the convenience of the United States District Judge.

1. Treatment for Back and Lower Extremity Pain

On January 26, 2012, Claimant presented to the emergency room, complaining of "severe" pain in her lumbar spine that began one month prior after she slipped and fell at home. (Tr. at 1740.) Her back was tender in the "lumbar area," and she had decreased range of motion on flexion and extension. (Id. at 1741.) An x-ray revealed evidence of levoscoliosis but was otherwise unremarkable. (Id.) Claimant was diagnosed with back pain and prescribed pain medication and a muscle relaxer. (Id. at 1741-42.)

Claimant again presented to the emergency room on July 15, 2012, complaining of "moderate" lower back and chest pain caused by a fall at home. (Id. at 1648.) Upon physical examination, there was muscle tenderness in Claimant's back, but her range of motion was normal. (Id. at 1649.) X-rays of Claimant's lumbar spine and pelvis were negative. (Id.) She was diagnosed with a low back strain and prescribed a muscle relaxer. (Id.)

Claimant presented to the emergency room on September 19, 2012, complaining of "severe" pain and "grinding" in her right knee after she twisted and hyperextended it while walking. (Id. at 1623.) Although Claimant "complain[ed] of pain on weight bearing," there was "[n]o swelling, tingling, weakness, numbness or suspected foreign body." (Id.) Upon physical examination, Claimant walked with a limp. (Id. at 1625.) The examiner noted "mild tenderness located in the medial joint line" of her right knee and "[l]imited [range of motion] secondary to pain." (Id.) However, an x-ray was negative, and there was "[n]o change from 08/05/2011." (Id. at 1628.) Claimant was given pain medication and instructed to apply ice to the knee. (Id. at 1625.) She was also referred to an orthopedic surgeon. (Id.)

Five days later, on September 24, 2012, Claimant presented to the emergency room complaining of back pain that began when she was lifting a laundry basket three days earlier. (Id. at 1616.) She reported "moderate" pain in her lumbar spine that radiated into her legs and was "worsened by standing or walking." (Id.) It was noted that Claimant "was seen recently at this facility (This is the patient's 24th pain related visit this year.)." (Id.)4 Upon physical examination, Claimant's back appeared normal. (Id. at 1617.) Therewas "[m]ild soft tissue tenderness in the right lower lumbar area" but "[p]ainless [range of motion]." (Id.) Claimant also had a normal range of motion in her extremities. (Id.) Imaging of Claimant's lumbar spine revealed "[c]hronic levo-scoliosis with scoliosis angle measured between T10 and L3 of 30 degrees," and the findings were similar to the imaging conducted on July 15, 2012. (Id. at 1620.) Claimant was diagnosed with an acute back strain and "referred to the spine center." (Id. at 1617.)

On February 19, 2013, Claimant presented to the emergency room, complaining of a lower back injury after a fall at home. (Id. at 1584.) She reported "moderate pain" but "no pain on weight bearing." (Id.) A physical examination revealed tenderness in the "lower lumbar area" but "[n]o vertebral point tenderness, muscle spasm or limitation in [range of motion]." (Id. at 1585.) Claimant was observed to have "[n]o limping gait." (Id.) Imaging was unremarkable. (Id. at 1586.) She was diagnosed with a contusion and prescribed pain medication. (Id.)

Claimant again presented to the emergency room on March 14, 2013, complaining of "moderate pain" in her right knee and ankle after a fall down one stair. (Id. at 1573.) Upon physical examination, she had "moderate tenderness and mild swelling" in her right knee and "moderate tenderness" in her right ankle. (Id. at 1574.) Her range of motion was limited "secondary to pain" in both her knee and her ankle. (Id.) Imaging of the knee and ankle was "negative." (Id.) Claimant was diagnosed with a sprained right knee and ankle and was prescribed medication and directed to apply ice to the injury. (Id. at 1574-75.)

Just over a month later, on April 24, 2013, Claimant presented to the emergency room with "severe" left leg pain that began after she "stepped awkwardly off the curb going after [a basketball]." (Id. at 1562.) Upon physical examination, Claimant had"moderate tenderness" in her left knee and ankle and "[l]imited [range of motion] secondary to pain" but no swelling, and x-rays were "negative." (Id. at 1563.) She was diagnosed with a sprained knee and ankle, prescribed medication, and instructed to apply ice and use crutches. (Id. at 1564.)

Claimant returned to the emergency room several weeks later, on May 8, 2013, continuing to complain of lower extremity pain caused by the April 24 fall. (Id. at 1558.) It was noted that she "was seen recently at this facility (7th ED visit this year)." (Id.) There was "moderate tenderness" in Claimant's left foot, and it was noted, "Foot exam grossly negative. Pain out of proportion to findings." (Id. at 1559.) An x-ray of Claimant's left foot revealed "[n]o fracture" and "[n]ormal alignment." (Id.) It was noted that Claimant had "crutches at home." (Id.) She was diagnosed with a sprained left foot and again instructed to apply ice, wrap her foot with a bandage, and use crutches. (Id. at 1560.)

Claimant presented to the emergency room again on September 3, 2013, complaining of "severe" pain in her lumbar spine that radiated to her buttocks. (Id. at 1485.) She stated that she injured herself while getting out of her vehicle. (Id.) It was noted that Claimant "was seen recently at this facility" and "frequents this ER for various complaints, usually pain related" and that she "has been here an average of twice a month for the past 7 months." (Id.) Upon physical examination, there was "[m]oderate soft tissue tenderness in the mid central lumbar area" and "[s]everely limited [range of motion] in the back" upon flexion and rotation. (Id. at 1486.) She was diagnosed with an acute lumbar strain, prescribed medication, and directed to apply ice several times per day. (Id. at 1487.) Several weeks later, on September 30, 2013, Claimant presented to her primary care provider,...

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT