United States District Court, E.D. Tennessee, Greeneville
REPORT AND RECOMMENDATION
Clifton L. Corker, United States Magistrate Judge
matter is before the United States Magistrate Judge, under
the standing orders of the Court and 28 U.S.C. § 636 for
a report and recommendation. Plaintiff's claims for
Disability Insurance Benefits and Supplemental Security
Income were denied administratively by Defendant Commissioner
following a hearing before an Administrative Law Judge
[“ALJ”]. This is an action for judicial review of
that final decision of the Commissioner. The plaintiff has
filed a pro se Complaint [Doc. 1], asking the Court
to award her benefits, and followed that with a one page
Motion for Summary Judgment [Doc. 13]. Defendant Commissioner
has filed a Motion for Summary Judgment [Doc. 21].
Standard of Review
sole function of this Court in making this review is to
determine whether the findings of the Commissioner are
supported by substantial evidence in the record.
McCormick v. Secretary of Health and Human Services,
861 F.2d 998, 1001 (6th Cir. 1988).
“Substantial evidence” is defined as evidence
that a reasonable mind might accept as adequate to support
the challenged conclusion. Richardson v. Perales,
402 U.S. 389 (1971). It must be enough to justify, if the
trial were to a jury, a refusal to direct a verdict when the
conclusion sought to be drawn is one of fact for the jury.
Consolo v. Federal Maritime Commission, 383 U.S. 607
(1966). The Court may not try the case de novo nor
resolve conflicts in the evidence, nor decide questions of
credibility. Garner v. Heckler, 745 F.2d 383, 387
(6th Cir. 1984). Even if the reviewing court were
to resolve the factual issues differently, the
Commissioner's decision must stand if supported by
substantial evidence. Listenbee v. Secretary of Health
and Human Services, 846 F.2d 345, 349 (6th
Cir. 1988). Yet, even if supported by substantial evidence,
“a decision of the Commissioner will not be upheld
where the SSA fails to follow its own regulations and where
that error prejudices a claimant on the merits or deprives
the claimant of a substantial right.” Bowen v.
Comm'r of Soc. Sec., 478 F.3d 742, 746
(6th Cir. 2007).
Sequential Evaluation Process
applicable administrative regulations require the
Commissioner to utilize a five-step sequential evaluation
process for disability determinations. 20 C.F.R. §
404.1520(a)(4). Although a dispositive finding at any step
ends the ALJ's review, see Colvin v. Barnhart,
475 F.3d 727, 730 (6th Cir. 2007), the complete sequential
review poses five questions:
1. Is the claimant engaged in substantial gainful activity?
2. Does the claimant suffer from one or more severe
3. Do the claimant's severe impairments, alone or in
combination, meet or equal the criteria of an impairment set
forth in the Commissioner's Listing of Impairments (the
“Listings”), 20 C.F.R. Subpart P, Appendix 1?
4. Considering the claimant's RFC, can he or she perform
his or her past relevant work?
5. Assuming the claimant can no longer perform his or her
past relevant work -- and also considering the claimant's
age, education, past work experience, and RFC -- do
significant numbers of other jobs exist in the national
economy which the claimant can perform?
20 C.F.R. § 404.1520(a)(4). A claimant bears the
ultimate burden of establishing disability under the Social
Security Act's definition. Key v. Comm'r of Soc.
Sec., 109 F.3d 270, 274 (6th Cir. 1997). It is important
to note, especially in this case, that even if the ALJ finds
a severe impairment, that does not end the analysis. The ALJ
still must continue along the sequential process in order to
determine whether a particular claimant satisfies the
filed this pro se complaint alleging that the ALJ
“ruled without having or reviewing relevant ongoing
medical diagnosis of [her] condition and disabilities per
code of Federal Regulations….” [Doc. 1-1, pg.
1]. She noted that after being denied benefits requested to
present additional evidence. [Doc. 1-3, pg. 1]. She indicated
that she has been treated for Cushing's Syndrome and that
the specialist to whom she had been referred was at
Vanderbilt University Hospital. Her specialist's
appointment was six months out. She indicates that
“[t]here has been ongoing medical discovery as stated
in my request for additional time.” [Doc. 1-3]. She
“disputes” the findings of the consultative
examiner, Dr. Robert Blaine. She claims he was not qualified
to render his opinion. She also claims that he did not
explain “how my Cushing Syndrome compounded with my
BPES was causing my medical condition/disabilities listed in
my claim.” [Id.]. She also claims she was
misdiagnosed by the doctors. She also claims that the ALJ
“did not have all the facts….”
[Id.]. Finally, she argues that she had been
“told by the medical specialist that [her] ongoing
medical condition … related to the Cushing Syndrome is
at a very serious level and can become life threatening and
is physically debilitating.” [Doc. 1-4, pg. 1].
making these arguments, she filed a letter and seven exhibits
with the Court also raising similar issues [Doc. 5]. Here she
claimed she needed additional time before a decision was
rendered on her disability claim because Cushing's
syndrome takes a long time to diagnose. [Doc. 5, pg. 1]. In
this document, she summarized her treatment history and
outlined her physical and mental limitations, much like she
did before the ALJ at the administrative hearing. She
submitted additional medical records for the Court to
consider [Docs. 5-2(Attachment A) - 5-8(Attachment G).
Evidence in the Record
Commissioner has accurately summarized the medical evidence
of record in this case:
Plaintiff underwent a left side L4-L5 discectomy in July 2012
due to chronic back pain and radiculopathy-type symptoms in
her left leg (Tr. 256-58). At her follow-up appointment, she
reported improvement; two weeks after the surgery, she was
able to actively flex and extend the hips, knees, ankles, and
toes without focal deficit, and a straight leg raise test was
negative (Tr. 232).
In May 2013, Plaintiff went to the emergency room and
reported a six-day history left eye redness, swelling,
numbness, and tingling (Tr. 252-53). She did not report any
other symptoms, including back pain (Tr. 252-53).
Musculoskeletal and neurological examinations were
unremarkable (Tr. 254). …
In August 2013, Plaintiff underwent a complete hysterectomy
(Tr. 289-91, 341-43, 395-97). Following her recovery from
this surgery, she returned to work for a short while in
October 2013, but she “could not handle this new
position” and was let go (Tr. 170). In mid- October
2013, Plaintiff went to Acute Care with a sudden onset of
back pain that she described as a spasm (Tr. 426). She
reported that her back surgery the prior year had worked
“very well with nearly complete relief”
(Id.). She reported she had been “somewhat
stressed lately” and had recently become unemployed
(Id.). The doctor noted Plaintiff moved slowly
“as if concerned about pain” (Tr. 427). Her lower
back was tender and flexion and extension of her back caused
significant pain (Id.). Straight leg raising testing
was negative (Id.). The doctor assessed back pain
and lumbar strain, as well as acute reaction to stress
(Id.). He prescribed Toradol, Cyclobenzaprine, and
alprazolam (Xanax) (Id.).
Plaintiff had a history of diverticulitis and underwent
surgery for a bowel perforation in January 2014 (Tr. 299-303,
334-36, 371-74). A CT scan also showed bilateral adrenal
masses typical of benign adenomas, and she was referred to
endocrinology for further investigation (Tr. 299-300, 472).
Following her surgery, in February 2014, Plaintiff reported
she was doing well and was ambulating, passing gas, and had
no further episodes (Tr. 366-67). April 2014 imaging revealed
an enlarged thyroid gland with cysts as well as the adrenal
masses (Tr. 419-20).
At her routine health examination in August 2014, Plaintiff
told her primary care doctor that she was “doing well
medically” and “life [was] good” (Tr.
448-49). She had recently moved to a small town and had
stopped taking fluoxetine because she “felt better with
regards to her mood” following the move (Tr. 448). She
admitted that her back problems were “resolved after
surgery” and thus she had not taken any pain
medications on a regular basis (Id.). She denied
headaches, nausea, vomiting, or problems with muscles, bones,
or joints (Tr. 449). Physical examination was unremarkable
(Tr. 449). Her doctor restarted many of Plaintiff's
medications and noted she would be following up with her
endocrinologist at Vanderbilt later that year (Tr. 450).
Plaintiff applied for disability insurance benefits in
December 2014 (Tr. 147). In February 2015, at the initial
level of review, State agency medical consultant Joseph
Curtsinger, M.D., opined that during an 8-hour workday,
Plaintiff could lift and carry 20 pounds occasionally and 10
pounds frequently, stand and walk for about 6 hours, and sit
for about 6 hours, with an unlimited ability to push and pull
(Tr. 71). She had no postural, manipulative, visual,
communicative, or environmental limitations (Id.).
In August 2015, she established primary care at Rural Health
Services Consortium, Inc. (Tr. 616-22). Plaintiff summarized
her health history, and reported current symptoms of anxiety,
bilateral lower extremity pain and numbness, and headaches
(Tr. 616-20). Plaintiff stated her anxiety was associated
with headache, irritability, and urinary frequency, but
denied any nausea, vomiting, or weight gain (Tr. 616).
Plaintiff attributed her anxiety to enlarged adrenal glands
(Id.). Her leg pain hurt mostly in the mornings but
was relieved by using sneakers (Id.). As for her
headaches, they had begun one year earlier, were moderate,
occurred daily, and were usually quickly resolved with
over-the-counter Advil and rest, but could sometimes last two
days (Tr. 617). Although not discussed in her history of
present illness, Plaintiff also endorsed dizziness and back
pain in her review of symptoms (Tr. 619-20). On examination,
the only positive finding was bunions on both feet (Tr. 620).
The provider assessed foot joint pain, generalized ...