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Walker v. Berryhill

United States District Court, S.D. West Virginia, Charleston Division

April 25, 2018

ROBERT KENNETH WALKER, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          PROPOSED FINDINGS AND RECOMMENDATIONS

          CHERYL A. EIFERT UNITED STATES MAGISTRATE JUDGE.

         This action seeks a review of the decision of the Commissioner of the Social Security Administration (hereinafter “Commissioner”) denying Plaintiff's applications for a period of disability and disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381-1383f. The matter is assigned to the Honorable John T. Copenhaver, Jr., United States District Judge, and was referred to the undersigned United States Magistrate Judge by standing order for submission of proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). Presently pending before the Court are Plaintiff's Brief in Support of Judgment on the Pleadings and the Commissioner's Brief in Support of Defendant's Decision, requesting judgment in her favor. (ECF Nos. 10, 11).

         Having fully considered the record and the arguments of the parties, the undersigned United States Magistrate Judge respectfully RECOMMENDS that Plaintiff's request for judgment on the pleadings be DENIED, the Commissioner's request for judgment on the pleadings be GRANTED, the Commissioner's decision be AFFIRMED, and that this case be DISMISSED and removed from the docket of the Court.

         I. Procedural History

         On November 15, 2013, Plaintiff Robert Kenneth Walker (“Claimant”), completed applications for DIB and SSI, alleging a disability onset date of October 21, 2013, on the basis that he was “unable to focus” and had a degenerated disc in his lower back, sciatica, severe migraine headaches, a cyst in the back of his head, high blood pressure, and gout. (Tr. at 195-208, 229). The Social Security Administration (“SSA”) denied Claimant's applications initially and upon reconsideration. (Tr. at 19). Claimant filed a request for an administrative hearing, which was held on March 25, 2016 before the Honorable David Thompson, Administrative Law Judge. (Tr. at 39-75). By written decision dated May 31, 2016, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 16-38). The ALJ's decision became the final decision of the Commissioner on February 21, 2017, when the Appeals Council denied Claimant's request for review. (Tr. at 1-7).

         Claimant timely filed the present civil action seeking judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner subsequently filed an Answer opposing Claimant's complaint and a Transcript of Proceedings. (ECF Nos. 8, 9). Claimant then filed a Brief in Support of Judgment on the Pleadings, (ECF No. 10), and the Commissioner responded with a Brief in Support of Defendant's Decision. (ECF No. 11). Therefore, the matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 34 years old at the time of his alleged onset of disability and 36 years old at the time of the ALJ's decision. Claimant completed high school and was trained in automotive service technology. (Tr. at 230). He communicates in English and previously worked as an automotive service manager, mechanic, and food deliverer. (Tr. at 62-63, 228).

         III. Summary of ALJ's Decision

         Under 42 U.S.C. § 423(d)(5), a claimant seeking disability benefits has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972). A disability is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable impairment which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

         The Social Security regulations establish a five-step sequential evaluation process for the adjudication of disability claims. If an individual is found “not disabled” at any step of the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The first step in the sequence is determining whether a claimant is currently engaged in substantial gainful employment. Id. §§ 404.1520(b), 416.920(b). If the claimant is not, then the second step requires a determination of whether the claimant suffers from a severe impairment. Id. §§ 404.1520(c), 416.920(c). A severe impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” Id. If severe impairment is present, the third inquiry is whether this impairment meets or equals any of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4 (the “Listing”). Id. §§ 404.1520(d), 416.920(d). If so, then the claimant is found disabled and awarded benefits.

         However, if the impairment does not meet or equal a listed impairment, the adjudicator must assess the claimant's residual functional capacity (“RFC”), which is the measure of the claimant's ability to engage in substantial gainful activity despite the limitations of his or her impairments. Id. §§ 404.1520(e), 416.920(e). After making this determination, the fourth step is to ascertain whether the claimant's impairments prevent the performance of past relevant work. Id. §§ 404.1520(f), 416.920(f). If the impairments do prevent the performance of past relevant work, then the claimant has established a prima facie case of disability, and the burden shifts to the Commissioner to demonstrate, in the fifth and final step of the process, that the claimant is able to perform other forms of substantial gainful activity, given the claimant's remaining physical and mental capacities, age, education, and prior work experiences. 20 C.F.R. §§ 404.1520(g), 416.920(g); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The Commissioner must establish two things: (1) that the claimant, considering his or her age, education, skills, work experience, and physical shortcomings has the capacity to perform an alternative job, and (2) that this specific job exists in significant numbers in the national economy. McLamore v. Weinberger, 538 F.2d 572, 574 (4th Cir. 1976).

         Here, the ALJ determined as a preliminary matter that Claimant met the insured status for disability insurance benefits through December 31, 2018. (Tr. at 21, Finding No. 1). At the first step of the sequential evaluation, the ALJ found that Claimant had not engaged in substantial gainful activity since the alleged onset date, October 21, 2013. (Id., Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant had the following severe impairments: “degenerative disc disease, headaches (alleged migraines), and obesity.” (Tr. at 22, Finding No. 3). Under the third inquiry, the ALJ found that Claimant did not have an impairment or combination of impairments that met or medically equaled any of the impairments contained in the Listing. (Tr. at 24, Finding No. 4). Accordingly, the ALJ determined that Claimant possessed:

[T]he residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except limited to occasional climbing of ramps, stairs, and ladders; no climbing of ladders, ropes and scaffolds; occasional stooping, kneeling, crouching and crawling; and must avoid concentrated exposure to noise above Level IV, and fumes, dusts, gases, unprotected heights and unprotected moving machinery.

(Tr. 24-31, Finding No. 5). At the fourth step, the ALJ found that Claimant was unable to perform any past relevant work. (Tr. at 31, Finding No. 6). Under the fifth and final inquiry, the ALJ reviewed Claimant's past work experience, age, and education in combination with his RFC to determine his ability to engage in substantial gainful activity. (Tr. at 31, Finding Nos. 7-10). The ALJ considered that (1) Claimant was born in 1979 and was defined as a younger individual on the alleged disability onset date; (2) he had at least a high school education and could communicate in English; and (3) transferability of job skills was not material to the disability determination because the Medical-Vocational Rules supported a finding that Claimant was “not disabled, ” regardless of his transferable job skills. (Tr. at 31, Finding Nos. 7-9). Given these factors, Claimant's RFC, and the testimony of a vocational expert, the ALJ determined that Claimant could perform jobs that existed in significant numbers in the national economy, (Tr. at 31-32, Finding No. 10), including work as an inventory clerk, service writer, or sales employee at the light exertional level, or personnel interviewer or time keeper at the sedentary exertional level. (Tr. at 32). Therefore, the ALJ concluded that Claimant was not disabled as defined in the Social Security Act, and thus, he was not entitled to benefits. (Id., Finding No. 11).

         IV. Claimant's Challenge to the Commissioner's Decision

         Claimant asserts that the Commissioner's decision is unsupported by substantial evidence because the ALJ failed to properly consider the impact of his migraine headaches. (ECF No. 10). Specifically, Claimant contends that the ALJ's step three analysis was conclusory and failed to identify the specific listing to which Claimant's medical findings for his migraine headaches should have been compared. (Id. at 12-15). In addition, Claimant states that the ALJ's pain analysis and credibility findings were not in compliance with applicable regulatory and case law, because the ALJ relied almost exclusively on objective evidence to discredit Claimant's allegations of disabling pain and did not demonstrate how Claimant's statements were inconsistent with the evidence. (Id. at 6-12). Finally, within his challenge to the credibility analysis, Claimant contends that “the ALJ declined to provide any limitations in [Claimant's] RFC assessment that related to the obvious absenteeism or the need for additional rest breaks that would occur as a result of [Claimant's] migraine headache episodes.” (Id. at 12).

         In response to Claimant's arguments, the Commissioner argues that the ALJ complied with all applicable laws, provided an exemplary pain and credibility analysis, and thoroughly analyzed all of the evidence concerning Claimant's migraine headaches. (ECF No. 11).

         V. Relevant Evidence

         The undersigned has considered all of the evidence of record, including documentation of medical examinations, treatment, evaluations, and statements. The information that is most relevant to Claimant's challenge is summarized as follows.

         A. Treatment Records

         In January 2011, several years prior to Claimant's alleged onset of disability and while he was still employed, Claimant's primary care provider, Amado Gabriel Maijub, M.D., Ph.D., referred him to PARS Neurosurgical Associates, Inc. (“PARS”) for an evaluation of headaches, which reportedly began three weeks earlier. (Tr. at 505). During Claimant's subsequent visit with Dr. Maijub a few months later on March 22, 2011, migraine headaches were included in Claimant's list of complaints and assessed conditions, but Claimant denied having a headache at the time of the visit. (Tr. at 308-09). He was alert, fully oriented, and in no acute distress. (Id.). His mental status and eye movements were normal. (Id.). Dr. Maijub prescribed Topamax to treat Claimant's headaches. (Tr. at 309).

         Claimant returned to PARS for follow-up on March 28, 2011. He advised nurse practitioner, Sheena Geer, that his symptoms had improved 50 to 75 percent. He had suffered only two migraines since his initial appointment in January. (Tr. at 510). Claimant continued to take Topamax. (Id.).

         On December 20, 2011, Claimant saw a neurologist, Jay A. Bauerle, M.D. Claimant reported ongoing headaches, but stated that he had them only once or twice a week as compared to the daily headaches that he previously experienced. (Tr. at 539). Claimant was taking Topamax twice per day, which was reducing the frequency of his headaches, and he was taking Imitrex at the onset of a headache, which was effective for acute treatment. (Tr. at 539, 541). Claimant noted that medication resolved his headaches in approximately one hour. (Tr. at 539). He added that numbness and tingling in his fingers and toes, which were a side effect of Topamax, had much improved. (Id.). On his review of systems, Claimant reported headaches, but denied vision issues, dizziness, nausea, vomiting, weakness, or difficulty with memory or concentration. (Tr. at 540-41). Dr. Bauerle's differential diagnosis included migraines without aura, mention of intractable migraine, or status migrainosus (a headache lasting more than 72 hours). (Tr. at 541). Claimant was continued on Topamax and Imitrex. (Id.).

         Claimant saw Dr. Maijub again on April 17, 2012. He denied having a headache; was alert, fully oriented, and in no acute distress; and his mental status and eye movements were normal. (Tr. at 453-54). The following month, on May 7, 2012, Claimant again followed-up at PARS. On a review of systems, Claimant reported headaches, but denied double vision or other vision issues, dizziness, nausea, vomiting, loss of balance, lack of concentration, or memory difficulties. (Tr. at 516). His headaches were improving. (Tr. at 517).

         Claimant next saw Dr. Bauerle on June 12, 2012. Claimant still reported having headaches once or twice per week that resolved in approximately one hour after taking medication. (Tr. at 543). He reported photophobia, but denied vision changes, dizziness, nausea, vomiting, weakness, difficulties with memory, or lack of concentration. (Tr. at 543-45). He reported a small decrease in headache frequency and intensity with an increased dosage of Topamax. (Tr. at 543). Claimant also stated that one dose of Imitrex was generally effective as an abortive treatment. (Id.). Claimant denied having any difficulty or intolerance with either medication. (Id.). Although Claimant showed some improvement, Dr. Bauerle felt that Claimant's reported migraines were still too frequent. (Tr. at 545). Thus, he increased Claimant's dosage of Topamax and advised him to take Aleve in conjunction with Imitrex for acute headaches. (Tr. at 546).

         On August 8, 2012, Claimant saw physician's assistant, Brian P. Showalter, at PARS. (Tr. at 520). Claimant's headaches were still improving. (Tr. at 520, 522). His gait was normal, without suggestion of weakness, and he did not grimace or show obvious signs of pain. (Tr. at 522). Similarly, at his October 3, 2012 visit with Dr. Maijub, Claimant denied having a headache, was alert, fully oriented, and in no acute distress. (Tr. at 297). Claimant followed up with Dr. Bauerle later in the year on December 11, 2012. (Tr. at 547). The frequency of his headaches had reduced to a severe headache every other week as opposed to his prior reports of one to two headaches per week. (Id.). Claimant was taking Topamax daily and Imitrex as needed. (Id.). He stated that Imitrex alleviated his headaches, and he denied symptoms of photophobia, phonophobia, nausea, dizziness, loss of balance, or vision disturbances. (Id.). Nonetheless, given that Claimant continued to have headaches, Dr. Bauerle again increased Claimant's dosage of Topamax. (Tr. at 549).

         Claimant saw Dr. Maijub on May 1, 2013. Like his prior visits, his list of complaints and assessed conditions included headaches, although he denied having a headache at the time of the visit and was alert, fully oriented, and in no acute distress. (Tr. at 294). The following month, on June 11, 2013, Claimant saw Dr. Bauerle. (Tr. at 551). Claimant reported three to four headaches per month, as opposed to his previous report of four to eight headaches per month and noted that he was taking his medications without difficulty. (Id.). Claimant stated that he vomited once since his last visit. (Id.). Claimant's diagnosis remained the same, but because he was still requiring Imitrex for acute headaches on a fairly frequent basis, Dr. Bauerle again increased Claimant's dosage of Topamax. (Tr. at 553). Claimant was accompanied by his wife and children at the visit; he was in no acute distress, with normal attention and gait; and his affect was appropriate. (Tr. at 551, 553).

         On July 15, 2013, Claimant saw Mr. Showalter at PARS. Claimant reported that he was still having severe headaches, but they were tolerable with medication. (Tr. at 524). On a review of systems, Claimant reported dizziness and lightheadedness, but denied loss of balance. (Tr. at 526). Claimant was neurologically intact, and his brain MRI was stable. ...


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