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Allton v. Berryhill

United States District Court, E.D. Tennessee, Greeneville

July 16, 2019

NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Clifton L. Corker, United States Magistrate Judge

         This 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].

         I. Standard of Review

         The 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).

         II. Sequential Evaluation Process

         The 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 impairments?
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 disability criteria.

         III. Plaintiff's Arguments

         Allton 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].

         After 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).

         IV. Evidence in the Record

         The 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 ...

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