Ray v. Colvin
| Decision Date | 04 September 2014 |
| Docket Number | Civil Action No. 7:13-CV-00011-BL |
| Parties | ANDREW RAY CASE, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant |
| Court | U.S. District Court — Northern District of Texas |
Assigned to U.S. Magistrate Judge
Pursuant to 42 U.S.C. § 405(g), Plaintiff Andrew Ray Case seeks judicial review of the Commissioner of Social Security's decision, which denied his applications for a period of disability, disability insurance benefits, and supplemental security income benefits under Titles II and XVI of the Social Security Act. The United States district judge transferred this case to the United States magistrate judge and all parties consented to the jurisdiction of the magistrate judge.
After considering the pleadings, the briefs, and the administrative record, this Court affirms the Commissioner's decision and dismisses, with prejudice, Case's complaint.
Following a hearing on May 3, 2011, an Administrative Law Judge (ALJ) determined on June 23, 2011, that McFarland was not disabled. Specifically, the ALJ held that Case's impairments did not meet or equal any of the impairments listed in Appendix 1 of the governing regulations, that he had the residual functional capacity (RFC) to perform a wide range ofsedentary work, and that although he was not capable of performing his past relevant work, he was capable of performing other jobs existing in significant numbers in the national economy. The Appeals Council denied review on October 1, 2012. Therefore, the ALJ's decision is the Commissioner's final decision and is properly before the Court for review. See Higginbotham v. Barnhart, 405 F.3d 332, 334 (5th Cir. 2005) ().
Case filed an application for a period of disability, disability insurance benefits, and supplemental security income on July 22, 2009. (Tr. 8, 16, 134). Case claims he became disabled on July 17, 2009 (hereinafter date of onset), due to herniated discs at L4 and L5, severe back pain, spinal stenosis, hypertension, carpal tunnel syndrome, mental limitations, and disc bulges and foraminal narrowing of several vertebrae. (Tr. 8-9, 37, 59, 60, 61,63, 70, 74, 75, 134, 138). Previously, Case worked as a cashier, sales associate, pricing coordinator, office manager, mental health worker, and a psychiatric nurse's aide. (Tr. 139, 147). Case has a twelfth grade education and completed training to become an MHMR technician. (Tr. 37, 144-45).
Prior to the date of onset, Case obtained treatment for the various conditions he alleges are disabling. (Tr. 104-142, 170). In April 2008, Case was hit by a motor vehicle while riding his bicycle; his back pain started shortly thereafter. (Tr. 261). Between July and October of 2008, Case visited Dr. Maniago, M.D., for severe back pain. (Tr. 202). Case also visited Pain Rehab Group (Pain Rehab) several times between July 2008 and November 2009, and again between January 2010 and February 2011. (Tr. 238-70, 293-312).
During Case's numerous visits to Pain Rehab, he was under the care of Dr. Herren, M.D. (Tr. 238-70). These many visits were to evaluate, control, and treat Case's lower back pain. (Tr.238-70). On July 22, 2008, the back pain seemed to progressively radiate toward his left lower extremity. (Tr. 261). This pain caused Case some difficulty ambulating. (Tr. 261). X-rays ordered by Dr. Maniago shortly after the incident revealed no compression fractures, but did show that Case had some "degenerative changes at L4/5, and L5/S1." (Tr. 207, 261). An MRI scan done in May of 2008 revealed that Case had an L4/5 disc protrusion that was impinging the exiting nerve roots. (Tr. 205, 261). Severe right foraminal stenosis was also noted at L5/S1 along with hypertrophic changes of the facet joint. (Tr. 261). Case stated at this visit that his pain was a 9 on a 10 point scale, and ranges between a 7 and a 10 on the same scale. (Tr. 261). Case admitted his pain was alleviated when lying down but worsened during ambulation, moving about, and sitting. (Tr. 261). Dr. Herren did note that Case had a mild deterioration of strength. (Tr. 261). Case's medical history included hypertension, high cholesterol, asthma, major depression, and right carpel tunnel syndrome. (Tr. 262). Physical exam revealed that Case had "significant pain with palpatory examination of the lumbar paraspinal musculature particularly in the left lumbosacral triangle region." (Tr. 264). A straight leg test was mildly positive on the right. (Tr. 264). Dr. Herren then recommended that Case receive 3 lumbar epidural steroid injections in order to alleviate Case's symptoms. (Tr. 264). Medical records indicate that Case received one steroid injection in August 2008, and two in September 2008. (Tr. 258, 259, 260).
On October 20, 2008, Case followed up with Dr. Herren at Pain Rehab for a re-evaluation of back and right leg pain. (Tr. 257). At this visit, Case claimed that the epidural steroid injections he received earlier did not provide any relief. (Tr. 257). Notably, Dr. Herren reported that Case's straight leg raises were negative bilaterally and he had normal strength. (Tr. 257). On November 17, 2008, Case again returned to Dr. Herren for a follow up after the previous visit in October. (Tr. 256). At this visit, Dr. Herren re-evaluated Case's symptoms and placed him ondifferent medications for better pain management. (Tr. 256). On December 31, 2008, Case returned to Dr. Herren with complaints of chronic pain, and new pain symptoms on his right side. (Tr. 254). After reviewing an MRI scan, Dr. Herren opined that a transforaminal route injection may afford Case more relief from chronic pain. (Tr. 254). In January and February 2009, Case received the transforaminal lumbar epidural injection as prescribed by Dr. Herren. (Tr. 251, 252, 253).
In an April 2009 follow up visit to Pain Rehab, Dr. Herren noted that Case reported excellent relief after the second round of injections, but had since experienced some recurring pain. (Tr. 249). This pain was reported at a 7 on a 10 point scale. (Tr. 249). Physical exam revealed "moderate pain and discomfort across the lower lumbar region and pain into the right lower extremity." (Tr. 249). Case's straight leg exam was "mildly positive on the right and negative on the left." (Tr. 249). In July 2009, Case returned to Dr. Herren for a follow up visit where he reported that an incident where he was pushed into a wall two weeks earlier exacerbated his pain and caused his back to spasm. (Tr. 247). Case reported the post-incident pain to be a 9 on a 10 point scale. (Tr. 247). Physical examination at this visit revealed diaphoresis, hypertonic musculature in the lower lumbar region, and a positive left straight leg exam. (Tr. 247). Dr. Herren recommended a single transforaminal epidural steroid injection, which Case received on July 20, 2009. (Tr. 246-47). Case returned to Dr. Herren one week after the injection and reported that he only enjoyed a short-lived relief from the pain. (Tr. 245).
In October 2009, Case returned to Pain Rehab where he was treated by Dr. Robert Robey. (Tr. 240-243). At this visit, Case continued to complain of pain in his back and lower extremities. (Tr. 240). Physical exam of the thoracolumbar area revealed a full range of motion,negative Patrick's test,1 a negative straight leg raise, no tenderness on palpitation of bony structures, and paraspinous tenderness upon palpitation of the soft tissue. (Tr. 241). Dr. Robey also noted that Case had 5/5 muscle extension and 2+ stretch reflexes in his lower extremities. (Tr. 241).
In January 2010, Case returned to Pain Rehab complaining of back pain. (Tr. 310-12). In the progress report from this visit, Dr. Herren stated that it may be possible that Case was selling his medication—an allegation Case denied. (Tr. 310). Physical exam of the thoracolumbar area revealed a decreased range of motion and tenderness of the bony structures. (Tr. 311). Case revisited Pain Rehab in March, May, June, August, and November of 2010, and February 2011. (Tr. 293-310). Each of these visits was for treatment of his back pain. (Tr. 293-310). In March 2010, a thoracolumbar physical exam revealed Case had (Tr. 308). However, Dr. Herren also stated that he witnessed Case carrying his cane in his hand—making no use of it—in the parking lot of the clinic. (Tr. 308). Physical exam of the thoracolumbar region in August 2010 revealed a decreased range of motion, negative straight leg test, and tenderness of the bony structures upon palpation. (Tr. 301). Notably, in his November 2010 visit with Dr. Herren, a physical exam of the thoracolumbar region revealed a full range of motion, tenderness of the bony structures upon palpation, and tenderness of the soft tissue upon palpation. (Tr. 298). Finally, a physical exam of the thoracolumbar region conducted in February 2011 revealed a decreased range of motion, a negative Patrick's test, positive straight leg raise, right radiculopathy when seated, no tenderness upon palpation of bony structures, and tenderness upon palpation of soft tissue. (Tr. 294). Additionally, all muscle tests scored a 5/5, and all stretch reflexes scored a 2+. (Tr. 294). Thedoctor did note that Case "[t]alks about pain in an excessive manner." (Tr. 294).
In July 2009, Dr. Maniago sent Case to the Texas Back Institute, where he was seen by Dr. Stephen Hochschuler, M.D. (Tr. 200-01). During this visit, Dr. Hochschuler noted that Case had an increase in pain and that he was advised to stop working. (Tr. 201). Dr. Hochschuler also recommended that Case receive epidural injections, although there is no indication in the record that Case actually received this treatment from Dr. Hochschuler. (Tr. 200-01).
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