Michael T. B. v. Kijakazi
| Decision Date | 03 December 2021 |
| Docket Number | 20-cv-1779 (WMW/ECW) |
| Parties | Michael T. B., Plaintiff, v. Kilolo Kijakazi, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — District of Minnesota |
REPORT AND RECOMMENDATION
This matter is before the Court on Plaintiff Michael T. B.'s (“Plaintiff”) Motion for Summary Judgment (Dkt 21) and Defendant Acting Commissioner of Social Security Kilolo Kijakazi's (“Defendant”) Motion for Summary Judgment (Dkt. 23.) Plaintiff filed this case seeking judicial review of a final decision by Defendant denying his application for disability insurance benefits. This case has been referred to the undersigned United States Magistrate Judge for a report and recommendation pursuant to 28 U.S.C § 636 and Local Rule 72.1. For the reasons discussed below, the Court recommends that Plaintiff's Motion be denied, and Defendant's Cross-Motion be granted.
On July 11, 2017, Plaintiff filed a Title II application for a period of disability and disability insurance benefits, alleging disability as of January 31, 2017. (R. 15.)[1] His application was denied initially on December 1, 2017, and on reconsideration on February 5, 2018. (R. 186-191, 193-96.) Plaintiff filed a written request for a hearing, and on September 20, 2019, Plaintiff appeared and testified at a hearing before Administrative Law Judge Erin T. Schmidt (“the ALJ”). (R. 197-98, 215, 30-95.) The ALJ issued an unfavorable decision on November 22, 2019, finding that Plaintiff was not disabled. (R. 12-28.)
Following the five-step sequential evaluation process under 20 C.F.R. § 404.1520(a), [2] the ALJ first determined at step one that Plaintiff had not engaged in substantial gainful activity since January 31, 2017, the alleged onset date of disability. (R. 17.)
At step two, the ALJ determined that Plaintiff had the following severe impairments: degenerative joint disease and degenerative disc disease of the lumbar spine. (R. 17.)
At the third step, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. part 404, subpart P, appendix 1. (R. 18.)
At step four, after reviewing the entire record, the ALJ concluded that Plaintiff had the following residual functional capacity (“RFC”):
[T]o perform light work as defined in 20 CFR 404.1567(b) except the claimant can occasionally reach overhead bilaterally. He can frequently handle, finger, and reach in all other directions with the right, upper extremity. He can occasionally stoop, kneel, crouch, crawl, and climb. He can tolerate no more than occasional exposure to vibrations.
(R. 18-22.)
Based on the testimony of the vocational expert and a review of the record, the ALJ found at step four that Plaintiff was capable of performing his past relevant work as:
The ALJ found that the Plaintiff's past relevant work “does not require the performance of work-related activities precluded by the [Plaintiff's] residual functional capacity (20 CFR 404.1565).” (R. 22.) The ALJ also noted that the vocational expert's testimony accurately reflected Plaintiff's residual functional capacity and vocational background. (R. 22.)
Plaintiff requested review of the decision, and the Appeals Council denied Plaintiff's request for review, which made the ALJ's decision the final decision of the Commissioner. (R. 1-3.) Plaintiff then commenced this action for judicial review.
The Court has reviewed the entire administrative record, giving particular attention to the facts and records cited by the parties. The Court will recount the facts of the record only to the extent they are helpful for context or necessary for resolution of the specific issues presented in the parties' motions.
Plaintiff's complaints of extensive back, neck, and leg pain began after a vehicle accident on September 12, 2002. (R. 400.) Plaintiff had reported to Mathew J. Eckman, MD, for annual reviews in 2008 and 2009 of his neuromusculoskeletal complaints, particularly on his cervical, thoracic, and lumbar spine, and began seeing David J. Mast, MD, on January 29, 2010 for his pain. (R. 400-09, 437-440.) In 2011, Plaintiff reported that he had chronic low back pain resulting from working as a plumber/fitter and lifting 300-pound objects, a motorcycle accident, and the vehicle accident in 2002. (R. 480.) Since his accident in 2002, Plaintiff had received epidural injections at the L3-4 interspace, which improved his mobility, had multiple imaging studies performed of his back, and MRIs of the cervical, thoracic, and lumbar spines. (R. 451-52, 487-88, 491-93, 495-97.)
On April 22, 2010, an MRI of Plaintiff's cervical spine showed severe endplate degenerative changes and diffuse annular bulge and prominent endplate osteophytes at C5-6 (causes severe bilateral foraminal stenosis, slightly worse on the right when compared to the left). (R. 497.) There were also severe degenerative changes at ¶ 6-7 which demonstrated an annular bulge resulting in severe right foraminal stenosis and moderately severe to severe narrowing of the left neural foramen, associated with annular bulging and prominent endplate osteophyte formation. (R. 497-98.) There was a suggestion of mass effect on the intraforaminal portions of the C6 nerve roots at the C5-6 level and potential mass effect on the right C7 nerve root and dorsal root ganglion at the C6-7 level. (R. 497-98.)
An MRI of Plaintiff's thoracic spine also taken on April 22, 2010 showed no appreciable abnormality that accounted for Plaintiff's discomfort and no evidence of fracture within the thoracic spine or rib fracture. (R. 498-99.) However, there was a small right paracentral protrusion at ¶ 8-9 and tiny right paracentral protrusion at ¶ 7-8, which imparted minimal mass effect on the ventral aspect of the sac without evidence of neural compromise. (R. 498-99.)
On April 22, 2010, an MRI of Plaintiff's lumbar spine was taken. (R. 499-500.) It showed: an interval enlargement of an annular bulge at ¶ 3-4 resulting in bilateral lateral recess narrowing suggesting the possibility of intermittent mass effect on the exiting L4 nerve root bilaterally; an annular tear within the disc at ¶ 3-4 that possibly accounted for some of Plaintiff's discomfort; and new bony ankylosis of the SI joints that was potentially concerning for ankylosing spondylitis. (R. 499-500.)
Plaintiff underwent a neurosurgical consultation with Marshall Watson, MD, on May 17, 2010 for his cervical, thoracic, and lumbar pain, as well as pain from his neck to tailbone, tingling in his bilateral hands, intermittent pain in his buttocks, and tingling and throbbing pain in both legs. (R. 433.) The report from that visit notes that Plaintiff had experienced back pain for many years, however, his symptoms dramatically worsened after the 2002 car accident. (R. 435.) Dr. Watson stated in the report that “it can be somewhat difficult to pin down specific symptoms from” Plaintiff, and that while he thought some of Plaintiff's symptoms were coming from dysfunction at ¶ 5-6, C6-7, and L3-4, he was concerned that performing fusion surgery at any or all of those levels or disc arthroplasty was not going to substantially improve Plaintiff's overall level of pain and functioning, and that he saw no reason to rush into any surgical intervention to improve Plaintiff's symptoms. (R. 435-436.)
Plaintiff underwent a rheumatology consultation on May 10, 2010 that showed a full range of motion of the cervical spine of his neck and normal maintenance of lumbar lordosis in the back with no significant paraspinal muscle spasm and no focal areas of definable tenderness throughout the entire spine, as well as no SI joint tenderness. (R. 451-53.) X-rays of his sacroiliac joints during that visit showed some arthritis and narrowing of Plaintiff's left sacroiliac joint, which suggested some early degenerative arthritis in his hips, although the joints themselves appeared well preserved. (R. 467.)
Due to concerns regarding some ligamentous instability in Plaintiff's cervical spine, Dr. Mast referred Plaintiff to Dr. Jed Downs for evaluation, and on April 16, 2010, Dr. Mast opined that Plaintiff was feeling a little better, however, it was difficult for him to work beyond a few hours at a time and as a result, difficult for Plaintiff to be gainfully employed as a plumber. (R. 442, 444.) On April 28, 2010, Dr. Mast reported that Plaintiff's pathology showed “among the worst that [Plaintiff] ha[d] in the cervical MRI at ¶ 5-6 and C6-7 bilateral foraminal stenosis and mass effect at about C5-6.” (R. 447.)
On January 30, 2012, Dr. Mast reported that Plaintiff was continuing to have ongoing pain, including in his lower back which was “[w]orse on the left side in the lumbar radicular type of pattern and increasing now [Dr. Mast was] suspecting in his sacroiliac joint.” (R. 455, 457.) Plaintiff underwent a SI joint dysfunction/LT SI joint injection on February 6, 2012, which, as reported by Plaintiff, decreased pain in his left leg. (R. 662.) A MRI examination of the sacrum without contrast taken on July 3, 2012 showed evidence of prior spontaneous fusion of the anterior superior portions of Plaintiff's sacroiliac joints on both sides with no abnormality...
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