United States District Court, M.D. Tennessee, Nashville Division
REPORT AND RECOMMENDATION
JOE B. BROWN, Magistrate Judge.
This action was brought under 42 U.S.C. §§ 405(g) and 1383(c) for judicial review of the final decision of the Social Security Administration ("the SSA"), through its Commissioner ("the Commissioner"), denying plaintiff's applications for Disability Insurance Benefits (DIB) under Title II of the Social Security Act ("the Act"), 42 U.S.C. §§ 416(i) and 423(d), and Supplemental Security Income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381 et seq . For the reasons explained below, the undersigned RECOMMENDS that plaintiff's motion for judgment on the administrative record (Doc. 12) be DENIED and the Commissioner's decision AFFIRMED.
I. PROCEDURAL HISTORY
Plaintiff filed for DIB on March 11, 2012 and SSI on April 24, 2012. (Doc. 10, p. 14) Plaintiff alleged a disability onset date of January 1, 2009 for both. (Doc. 10, p. 14) Plaintiff claimed that he was unable to work because of knee problems, diabetes, vision problems, obesity, hypertension, and mental issues. (Doc. 12, pp. 131-32) The claims were denied initially on August 7, 2012 (Doc. 10, pp. 93-94), and upon reconsideration on December 5, 2012 (Doc. 10, pp. 124-25).
On January 9, 2013, plaintiff requested a hearing before an administrative law judge (ALJ) (Doc. 10, pp. 146-48) A hearing was held June 18, 2013 before ALJ Scott C. Shimer. (Doc. 10, pp. 33-72) Vocational expert (VE) Charles Wheeler testified at the hearing. (Doc. 10, pp. 68-70) Plaintiff was represented by counsel at the hearing. (Doc. 10, p. 33)
The ALJ entered an unfavorable decision on July 7, 2013. (Doc. 10, pp. 11-32) Plaintiff filed a request with the Appeals Council on September 8, 2013; to review the ALJ's decision. (Doc. 10, pp. 6-10) The Appeals Council denied plaintiff's request on October 17, 2013, whereupon the ALJ's decision became the final decision of the Commissioner. (Doc. 10, pp. 1-5)
Counsel brought this action on plaintiff's behalf on December 13, 2013. (Doc. 1) Plaintiff filed a motion for judgment on the administrative record on April 9, 2014 (Doc. 12), the Commissioner responded on August 7, 2014 (Doc. 18), and plaintiff replied on August 22, 2014 (Doc. 21). This matter is now properly before the court.
II. REVIEW OF THE RECORD
A. Medical Evidence
Plaintiff has provided 740-plus pages of medical records from the Tennessee Department of Correction (TDOC) covering the period June 9, 2011 to February 17, 2012. (Doc. 10, pp. 250-324, 504-1170) The TDOC records generally comprise medication administration and drug request forms, physician's orders, raw laboratory results, immunization records, progress reports, treatment plans, etc.
Dr. Lloyd Huang, M.D., an examining, nontreating source, examined plaintiff consultively on June 15, 2012. (Doc. 10, pp. 325-28) Doctor Huang, provided a written report of his examination, and completed a physical medical source statement (MSS). (Doc. 10, pp. 326-34)
A box captioned VISION CHECK" in Dr. Huang's handwritten clinical notes shows that plaintiff's uncorrected vision was 20/70 in each eye tested separately, and when tested together, and that his corrected vision was 20/15 in each eye tested separately, and when tested together. (Doc. 10, p. 325) The MSS assesses plaintiff as able to perform work at the light exertional level with the following relevant postural, manipulative, and environmental limitations: 1) standing 4 hrs. total in an 8 hr. workday, 2) occasional exposure to humidity, wetness, and extreme cold; 3) moderate noise. (Doc. 10, pp. 329-34) The MSS makes no reference to any visual limitations. (Doc. 10, p. 332)
Doctor Thelma Foley, Ed.D., an examining, nontreating source, conducted a mental status examination of plaintiff on July 10, 2012. (Doc. 10, pp. 336-38) Doctor Foley noted that "[n]o medical records were sent to [her], " but plaintiff "was an adequate personal historian." (Doc. 10, p. 336) Doctor Foley made the following relevant observations in her report based on plaintiff's subjective representations: 1) "he usually gets along with people but sometimes gets angry and yells"; 2) "[a]lthough he was friendly and cooperative today his history suggests that he gets angry easily which would cause him difficulty in a work setting." (Doc. 10, p. 338)
Plaintiff presented multiple times to the Mental Health Cooperative (MHC) from July 23, 2012 to September 7, 2012. (Doc. 10, pp. 354-409) Plaintiff was evaluated by psychiatrists Dr. Thomas Lavie, M.D., and Dr. Carmel Lakhani, M.D., both examining, nontreating sources. (Doc. 10, pp. 364-65, 397-98) Dr. Lavie wrote the following in his July 24, 2012 mental status exam:
Current mental status exam is unremarkable for any significant psychopathology, other than depression and psychomotor retardation.... There was no evidence of psychosis, mania, hypomania, sustained clinical depression or severe anxiety. Thought flow was coherent. No hallucinations currently, no delusions revealed. Level of consciousness was stable and alert. There was no evidence of movement disorder or psychomotor retardation or psychomotor agitation. Fred denied current suicide ideation.
(Doc. 10, pp. 364-65) Doctor Lakhani repeated Dr. Lavie's mental assessment verbatim in her July 27, 2012 report. (Doc. 10, p. 396) A MHC progress note dated August 3, 2012 recorded that plaintiff threatened to commit suicide if he were required to leave Room in the Inn (RITI) where MHC had arranged for him to stay temporarily. (Doc. 10, p. 402) A MHC progress note dated August 10, 2012 reported that plaintiff also left a letter in the waiting room of a clinic threatening to commit suicide if he were required to leave RITI. (Doc. 10, p. 403)
Plaintiff was seen at the Middle Tennessee Mental Health Institute (MTMHI) September 7, 2012 for suicidal ideations (SI). (Doc. 10, pp. 410-412) The MTMHI record notes that plaintiff's complaint was that he "need[ed] a place to stay, " that his representations of SI were "exaggerated, " and that he was "malingering for housing." (Doc. 10, pp. 411-12)
Plaintiff was treated at the Nashville General Hospital Emergency Department (ED) on September 13, 2012. (Doc. 10, pp. 413-20) The ED report notes that plaintiff intentionally took an overdose of insulin "in an attempt to avoid arrest." (Doc. 10, p. 414)
Plaintiff was treated at United Neighborhood Health Services (UNHS) from May 9, 2012 to October 12, 2012. (Doc. 10, pp. 479-502) Doctor Ada-Nkem Emuwa, M.D., noted following plaintiff's initial visit on May 9, 2012 that he exhibited "[m]ild depression, " but "[s]ymptoms are improved on medications...." (Doc. 10, pp. 479-80) Mary Carter conducted plaintiff's initial psychiatric evaluation on May 18, 2012. (Doc. 10, pp. 481-83) Plaintiff represented to Ms. Carter on June 1, 2012 that he was "[l]ooking forward to finding a job now that he ha[d] an ID." (Doc. 10, p. 484) Plaintiff also admitted throughout this period that he was not compliant with his medications. (Doc. 10, pp. 481, 487-88, 490-91, 493) Plaintiff's Global Assessment of Functioning (GAF) score was 30-40 during this time frame. (Doc. 10, pp. 483, 485, 488, 492, 502)
Dr. Sannagai Brown, M.D., a nonexamining, nontreating source, conducted a physical residual functional capacity (RFC) assessment of plaintiff on initial review on July 9, 2012. (Doc. 10, pp. 87-90) Doctor Brown noted that plaintiff had "20/70 corrected bilateral exam, " and that a "[c]omplete vision exam need[ed] to be performed." (Doc. 10, p. 88) Doctor Brown nevertheless determined that plaintiff could perform past relevant work (PRW) as "[a]ctually [p]erformed" and that, although "[t]he evidence shows that the individual ha[d] some limitations in the performance of certain work activities... these limitations would not prevent... [him]... from performing [PRW] work as a/an Parking Attendant." (Doc. 10, p. 91) Dr. Brown determined that plaintiff was not disabled. (Doc. 10, p. 92)
On November 19, 2012, Dr. Rebecca Sweeney, Ph.D., a nonexamining, nontreating source, conducted a mental RFC assessment upon reconsideration of the denial of plaintiff's application for benefits. (Doc. 10, pp. 108-110) Basing her opinion solely on Dr. Foley's assessment, Dr. Sweeney determined that plaintiff "ha[d] the ability to relate appropriately to supervisors and frequently with co-workers and with the general public." (Doc. 10, pp. 105, 110)(capitalization omitted)
On November 21, 2012, Dr. Karla Montague-Brown, M.D., a nonexamining, nontreating source, conducted a physical RFC assessment upon reconsideration of the denial of plaintiff's application. (Doc. 10, pp. 105-08) Doctor Montague-Brown noted that plaintiff had "G20/70 corrected bilateral exam, " and that the SSA would "need opthal[mologist] if gross vision results in AL." (Doc. 10, p. 107) As Dr. Brown before her, Dr. Montague-Brown determined that plaintiff could perform PRW as "[a]ctually [p]erformed" and that, although "[t]he evidence shows that the individual has some limitations in the performance of certain work activities... these limitations would not prevent the individual from performing [PRW] as a/an Parking Attendant." (Doc. 10, p. 112) Dr. Montague-Brown also determined that plaintiff was not disabled. (Doc. 10, p. 113)
Plaintiff has provided additional records from UNHS for the period October 19, 2012 to April 1, 2013. (Doc. 10, pp. 1172-1259) Ms. Jennifer Strickland, a UNHS behavioral specialist, noted on February 1, 2013 that plaintiff: 1) admitted "he sold his food stamps for money and has been buying candy and clothes" (Doc. 10, p. 1200); 2) stated on February 15, 2013 that he "[w]ant[ed] to... maintain contact with... friend, Debbie" (Doc. 10, p. 1188); 3) reported on March 15, 2013 that he had been "horse playing' with a friend'" and that "several peers... h[ad] befriended him and [we]re encouraging him" (Doc. 10, p. 1176). Plaintiff also admitted throughout this period that he was not compliant with his medications. (Doc. 10, pp. 1178, 1196, 1200, 1208, 1212, 1218) Plaintiff's GAF score during this period was 40-50. (Doc. 10, pp. 1173, 1175, 1177, 1183, 1185, 1189, 1195, 1201, 1213, 1215, 1217, 1231, 1233, 1238, 1243, 1245, 1247, 1249, 1259)
Finally, plaintiff has provided a letter dated February 25, 2013 from Ms. Strickland. (Doc. 10, p. 1171) Ms. Strickland's letter describes generally the services UNHS had provided plaintiff since May 9, 2002, but it does not address any objective medical evidence or ...