Betts v. Berryhill
| Decision Date | 09 April 2019 |
| Docket Number | CASE NO. 5:18CV1274 |
| Court | U.S. District Court — Northern District of Ohio |
| Parties | FRANKLIN M. BETTS, SR., Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant. |
MEMORANDUM OF OPINION AND ORDER
Plaintiff, Franklin M. Betts, Sr. ("Plaintiff" or "Betts"), challenges the final decision of Defendant, Nancy A. Berryhill,1 Acting Commissioner of Social Security ("Commissioner"), denying his applications for a Period of Disability ("POD"), Disability Insurance Benefits ("DIB"), and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, and 1381 et seq. ("Act").2 This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and the consent of the parties, pursuant to 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is AFFIRMED.
In January 2015, Betts filed applications for POD, DIB, and SSI, alleging a disability onset date of January 22, 2014 and claiming he was disabled due to L2 vertebra compression fracture, depression, post-traumatic stress disorder, and early onset dementia. (Transcript ("Tr.") at 28, 218, 268.) The applications were denied initially and upon reconsideration, and Betts requested a hearing before an administrative law judge ("ALJ"). (Tr. 28.)
On May 9, 2017, an ALJ held a hearing, during which Betts, represented by counsel, and an impartial vocational expert ("VE") testified. (Tr. 44-77.) On July 19, 2017, the ALJ issued a written decision finding Plaintiff was not disabled. (Tr. 28-43.) The ALJ's decision became final on April 10, 2018, when the Appeals Council declined further review. (Tr. 1-7.)
On June 5, 2018, Betts filed his Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 13, 15, 16.) Betts asserts the following assignments of error:
(Doc. No. 13.)
Betts was born in February 1967 and was forty-six (46) years-old at the time of his alleged disability onset date, making him a younger individual under social security regulations. (Tr. 36.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). He was fifty (50) years old at the time of his administrative hearing, causing him to change age categories to that of a person closely approaching advanced age. (Tr. 36.) He has at least a high school education and is able to communicate in English. (Id.) He has composite past relevant work as a material technician, extruder operator, and grinder. (Id.)
On May 8, 2013, Betts established treatment with primary care physician Jeffrey Monteith, M.D. (Tr. 535-546.) He complained of high stress, depressed mood, low energy, and sleep disturbance. (Tr. 535.) Physical examination findings were normal. (Tr. 536.) Dr. Monteith assessed obstructive sleep apnea, depression with anxiety, fatigue and malaise, hyperglycemia, and tobacco use disorder. (Id.) He ordered lab work and a sleep study, and prescribed Paxil. (Tr. 537, 539.)
Shortly thereafter, on May 15, 2013, Betts presented to the emergency room ("ER") after a motor vehicle accident. (Tr. 382-383.) He complained of mild headache, light lower back pain, and pain radiating down his right leg. (Id.) Examination revealed mild paraspinal muscular tenderness in Betts' cervical spine, diffuse lower lumbar pain, negative straight legraise, normal reflexes, and 5/5 muscle strength. (Id.) ER physicians diagnosed low back strain, prescribed Percocet and Flexeril, and discharged Betts in stable condition. (Tr. 382-383, 532.)
Betts returned to Dr. Monteith on June 19, 2013 for follow up. (Tr. 532-533.) He stated his pain was improving, but continued to complain of some radiating pain. (Id.) Betts also reported his depression was "better," and denied concentration problems. (Id.) Physical examination findings were normal, including normal spinal range of motion. (Id.) Dr. Monteith assessed back pain and depression with anxiety, and increased Betts' Paxil dosage. (Id.)
On June 20, 2013, Betts presented to the ER after falling down a flight of stairs. (Tr. 374-380.) He stated he landed on his lower back and left arm, and rated his pain an 8 on a scale of 10. (Tr. 374.) Examination revealed tenderness to Betts' upper lumbar area and an abrasion to his left elbow. (Id.) X-rays taken that date of Betts' lumbar spine showed a mild compression fracture at L2. (Tr. 379.) Betts received an injection of Dilaudid in the ER, and was prescribed Percocet. (Tr. 374.) He was discharged in stable condition with instructions to follow up with an orthopedist. (Id.) Several days later, Betts presented to Dr. Monteith, with complaints of pain in his back, shoulder, cervical spine, and left arm. (Tr. 529-530.) Dr. Monteith assessed closed fracture of the lumbar vertebra without spinal cord injury, and prescribed Percocet and ibuprofen. (Id.) The following month, Dr. Monteith advised Betts to "hold off on return to work" until he was seen by an orthopedist. (Tr. 526-527.)
On August 5, 2013, Betts established care with orthopedist Rajiv Taliwal, M.D. (Tr. 400-401.) On examination, Dr. Taliwal noted Betts was "visibly uncomfortable," with tenderness in his mid and upper lumbar region. (Tr. 400.) Betts was able to toe and heel walk, with normal motor strength, reflexes, sensation, and pulses. (Id.) Dr. Taliwal concluded Betts"has a mild injury that should go on to heal with time." (Id.) He encouraged Betts to avoid any heavy lifting, bending, or twisting. (Id.)
Betts returned to Dr. Taliwal on September 16, 2013. (Tr. 403-404.) He stated his pain continued to improve, rating it a 5 on a scale of 10. (Id.) Examination revealed back tenderness and stiffness, but was otherwise normal. (Id.) Dr. Taliwal stated "Betts continues to heal well clinically and radiographically." (Id.) He referred him to physical therapy. (Id.)
On October 24, 2013, Betts presented to Dr. Monteith with complaints of memory loss for the previous five years. (Tr. 523-524.) He reported as follows: (Id.) Physical examination findings were normal (including normal spinal range of motion), but Dr. Monteith found Betts' symptoms concerning. (Id.) He ordered an MRI of Betts' brain, and referred him to neurology. (Id.) Betts underwent the MRI on November 15, 2013, which revealed nonspecific subcortical and periventricular white matter changes that "may be seen with small vessel ischemic disease, demyelineating processes, among other etiologies." (Tr. 389-390.)
On December 9, 2013, Betts returned to Dr. Taliwal. (Tr. 406-407.) He reported "good days and bad days," and rated his back pain a 5 to 6 on a scale of 10. (Id.) Physical examination findings were normal, including normal range of motion, 5/5 muscle strength bilaterally, and negative straight leg raise. (Id.) Dr. Taliwal found Betts was "healing nicely" but stated "he may always have a little bit of discomfort." (Id.) He encouraged Betts to "increase activity as tolerated with no restrictions." (Id.)
Several days later, on December 11, 2013, Betts established care with neurologist Mita Deoras, M.D. (Tr. 618-620.) He reported the following symptoms:
Memory loss began about four years ago. Short term memory loss is most pronounced. He will often forget things he had just said a few minutes ago. He has difficulty remembering people's names. Last week at a doctor's appointment, he could not recall his home address or his home telephone number. He has gotten lost when driving, often to places he has been multiple times. When he gets clues or he is told what someone's name is, he will usually remember. He is able to remember memories from childhood. As far as day to day activities, he is able to do all [activities of daily living] independently. He works as a grinder technician for Rubbermaid. He has forgotten some technical aspects of his job, but this has not caused significant decline of job performance.
(Tr. 618.) On examination, Dr. Deoras found Betts was awake, alert, and oriented to person, place and time. (Tr. 619.) Betts' cognition and general fund of knowledge were fair, and he was able to repeat sentences and recall with verbal cues. (Id.) Betts was also able to identify objects and follow commands. (Id.) His muscle tone, strength, sensation, reflexes, coordination, and gait were all normal. (Id.) Dr. Deoras reviewed the results of Betts' MRI, and found "mild white matter changes, no evidence of acute ischemic abnormality, [and] no significant atrophy." (Tr. 619.) Dr. Deoras ordered lab work and a neuropsychological evaluation. (Tr. 620.) She also noted that Betts "has untreated [obstructive sleep apnea] and insufficient sleep- both of which can contribute to cognitive slowing and memory loss." (Id.) She stressed the importance of sleep apnea treatment and encouraged Betts to use his CPAP machine. (Id.)
On January 30, 2014, Betts presented to the ER after slipping and falling in his driveway. (Tr. 352-353.) Examination revealed midline tenderness throughout the lumbar spine, full range of motion, normal motor strength in all four extremities, and negative straight leg raise. (Id.) An x-ray taken that date showed no evidence of any acute fractures or dislocations but did reveal "some decreased height of the L2 vertebrae, which appears to bechronic compared to his prior...
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