Farmer v. Kijakazi
| Decision Date | 15 August 2022 |
| Docket Number | Civil Action 2:21-cv-00035 |
| Parties | KIPPY LEE FARMER, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Southern District of West Virginia |
PROPOSED FINDINGS & RECOMMENDATION
Plaintiff Kippy Lee Farmer (“Claimant” or “Plaintiff”) seeks review of the final decision of the Commissioner of Social Security (the “Commissioner”) denying his application for disability insurance benefits, a period of disability, and supplemental social-security income under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401433, 1381-1383f. (ECF No. 1.) By standing order entered on January 4, 2016, and filed in this case on January 15, 2021, 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 Brief in Support of Appeal and Motion for Remand (ECF No. 14), and the Commissioner's Brief in Support of Defendant's Decision (ECF No. 15).
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. 14), GRANT the Commissioner's request to affirm her decision (ECF No 15), AFFIRM the final decision of the Commissioner, and DISMISS this civil action from the Court's docket.
Claimant was 32 years old at the time of his alleged disability onset date and 42 years old on the date of the decision by the Administrative Law Judge (“ALJ”). (Tr. 51.)[1]The Claimant graduated from high school, where he participated in special education classes and received average grades. (Tr. 38-39, 226, 414.) Most recently, he worked as a Laborer at a sawmill for nine years until his alleged disability onset in 2010; he has also been employed as a Water-Softener Installer, Grocery Clerk, and Stamping-Press Operator. (Tr. 38, 102, 413.) Claimant alleges that he became disabled on September 1, 2010, due to “carpal tunnel; brain surgery on back of neck;” and “no balance.” (Tr. 52, 71, 88-91, 218-21.)
In February 2019, Claimant protectively filed an application for a period-of-disability and disability-insurance benefits, as well as an application for supplemental-security income. (Tr. 218-27.) His claim was initially denied on June 27, 2019, and again upon reconsideration on September 20, 2019. (Tr. 86, 120.) Thereafter, on October 30, 2019, Claimant requested a hearing before an ALJ. (Tr. 169.) An administrative hearing was held before ALJ Francine A. Serafin on April 16, 2020; the hearing was conducted telephonically by agreement of the parties due to the Covid-19 pandemic. (Tr. 32-50.) On May 19, 2020, the ALJ rendered an unfavorable decision. (Tr. 10-21.) Subsequently, Claimant sought review of the ALJ's decision by the Appeals Council; however, the Council denied Claimant's request for review on November 25, 2020, and the ALJ's decision then became the Commissioner's final decision on that date. (Tr. 1-3, 214-16.)
Claimant timely brought the present action on January 14, 2021, seeking judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (ECF No. 1.) The Commissioner filed an Answer, along with a transcript of the administrative proceedings (ECF Nos. 4, 5). Claimant subsequently filed, by counsel, his Brief in Support of Appeal and Motion for Remand. (ECF No. 14.) In response, the Commissioner filed her Brief in Support of Defendant's Decision. (ECF No. 15.) As such, this matter is fully briefed and ripe for resolution.
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.
On July 28, 2008, Claimant presented to neurosurgeon David L. Weinsweig, M.D., with complaints of headaches, neck pain, and some pain in his thoracolumbar region-all occurring over the previous six months to a year. (Tr. 337.) Dr. Weinsweig noted Claimant's medical history of brain surgery and “complete craniospinal neuraxial radiation” treatment to remove medulloblastoma, a cancerous tumor, with which he was diagnosed at the age of four. Id. Claimant denied any coordination problems or problems with his arms and legs, leading Dr. Weinsweig to note that “overall, he has done remarkably well” following his childhood cancer treatment. (Tr. 337; 423). Dr. Weinsweig also noted Claimant's past surgical history of bilateral carpal tunnel releases in 2003. (Tr. 337; see also Tr. 423.)
On examination, Dr. Weinsweig observed that Claimant's gait and tandem gait were normal; motor strength was grossly strong throughout the upper and lower extremities; sensation was intact, reflexes were equal, and there was no evidence of spasticity or myelopathy. (Tr. 337.) Brain and spine MRI and follow-up studies showed an intradural extramedullary lesion at ¶ 5-6, without evidence of diffuse metastasis. (Tr. 338.) Dr. Weinsweig diagnosed Claimant with possible recurrent cancer or other type of lesion, and at his recommendation Claimant elected a posterior cervical laminectomy at ¶ 5-8 to remove the lesion and relieve pressure on his spinal cord. Id. Subsequent cervical-spine imaging showed no evidence of a recurrent tumor, compression, or stenosis. (Tr. 339, 343, 350, 378.) The record does not indicate that Claimant had further complaints or treatment related to his cervical spine after the 2008 procedure.
In 2009, Claimant returned to Dr. Weinsweig with complaints of headaches and back pain. (Tr. 339.) On November 4, 2009, Dr. Weinsweig found that medical imaging indicated the signal in Claimant's spinal cord and vertebral marrow were normal; no Chiari malformation, acute bony abnormality or subluxation, abnormal enhancement, or recurrent tumor were observed; no cord-signal abnormalities were identified; and no significant cord compression was noted. (Tr. 339, 343.) Dr. Weinsweig concluded that there was “[n]o evidence for [a] recurrent tumor,” and Claimant's examination was stable. (Tr. 340-41.) However, Dr. Weinsweig found a “broad-based disc bulge at the L4-L5 level, which [wa]s causing moderate left and moderate to severe right neural foraminal narrowing.” (Tr. 340.) As “[t]he remaining levels [we]re unremarkable” and there was “no abnormal enhancement,” Dr. Weinsweig's diagnosis was “persistent minimal subluxation L4 on L5, with associated disc bulge and neural foraminal compromise.” (Tr. 340-41.) On March 7, 2010, Dr. Weinsweig ordered a sensory- response evaluation of Claimant's upper and lower extremities to evaluate for any returning tumor in his spinal cord. (Tr. 335-36.) The findings “indicate[d] normal conduction in the central sensory pathways to the posterior tibial stimulation.” (Tr. 336.) There is no indication on the record that Claimant sought or received treatment for pain during his treatment with Dr. Weinsweig.
On March 29, 2010, Claimant presented to Boone Memorial Hospital emergency room with “pain after injury at work” due to lifting. (Tr. 387-95.) Diagnostic x-rays of the lumbar spine indicated that Claimant did not have an acute fracture, but did present “decreased disc space height at ¶ 5-S1,” as well as “sacralization of L5,” which is a spinal irregularity of the fifth lumbar vertebra, associated with lower-back pain, posture control problems, and range-of-motion limitations. (Tr. 387-88.) Because sacralization can be congenital, the radiologist found that the decreased disc-space height “may be developmental rather than due to degenerative disc disease.” (Tr. 387.) Finally, the radiologist noted that “3 mm anterior subluxation of L4 is noted on L5 with no other malalignment,” which could be evaluated for possible “ligamentous instability.” Id. Claimant was diagnosed with low back strain and prescribed Flexeril, a muscle relaxant used to treat pain and stiffness caused by muscle spasms. (Tr. 389-91.) A follow-up MRI on April 12, 2010 indicated a localized central disc protrusion at ¶ 4-5 as well as a mild bulging disc at ¶ 5-S1, but no acute fracture or high-grade spinal stenosis. (Tr. 393-96.)
On December 29, 2014, Claimant presented to the emergency room at Boone Memorial Hospital with complaints of back pain. (Tr. 398.) Thoracic spine x-rays “reveal[ed] mild to moderate degenerative changes at multiple levels,” with “[n]o definite acute fracture or acute malalignment seen; Claimant was told to seek follow-up imaging if his back-pain symptoms persisted. Id. Following this 2014 treatment, the record does not contain evidence of any relevant medical treatment Claimant subsequently sought or received before initiating his February 2019 claim.
Claimant underwent a consultative internal-medicine examination with familymedicine physician Stephen Nutter, M.D., on June 13 2019. (Tr. 423-26.) Dr. Nutter wrote that Claimant “is a 41-year-old male claiming disability stating, ‘my wrists.'” (Tr. 423.) Claimant reported “problems with joint pain in the wrists, shoulders, and knees,” with intermittent joint pain for the previous five years. Id. He stated to Dr. Nutter that “walking, standing, kneeling, squatting and going up and down stairs increases the knee pain.” Id. Dr. Nutter wrote that Claimant “has had x-rays on both wrists,” followed by “bilateral carpal tunnel release in 2003.” Id. Claimant told Dr. Nutter that his carpal tunnel surgery ...
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