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Farmer v. Colvin

United States District Court, D. Kansas

April 29, 2015

CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.


KATHRYN H. VRATIL, District Judge.

Ricky Leon Farmer appeals the final decision of the Commissioner of Social Security to deny disability insurance benefits and supplemental security income (SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-434, 1281-1385. For reasons set forth below, the Court finds that the final decision of the Commissioner should be affirmed.

I. Procedural Background

Plaintiff was born in 1964. On August 19, 2009, plaintiff applied for disability insurance benefits under Title II and for SSI under Title XVI alleging a period of disability beginning October 1, 2003. Tr. 119-25, 126-33. The agency denied plaintiff's application initially and upon reconsideration. On January 25, 2012, following a hearing, an administrative law judge ("ALJ") found that plaintiff was not disabled as defined in the Social Security Act. Tr. 22. On July 26, 2013, the Appeals Council denied plaintiff's request for review. Tr. 1-3. The ALJ decision thus stands as the final decision of the Commissioner. See U.S.C. §§ 405(g), (h). Plaintiff appealed the final decision of the Commissioner to this Court.

II. Facts

The following is a brief summary of the evidence presented to the ALJ.

A. Medical Evidence

Duodenal Ulcer

From October 10 through 12, 2003, plaintiff received inpatient treatment at Integris Bass Baptist Health Center for a duodenal ulcer. He was re-admitted for inpatient care from October 13 through October 18, 2003. Since then he has suffered occasional flare-ups of the ulcer.

Mental Health Treatment

On July 11, 2009, plaintiff sought psychiatric and drug counseling at the Mental Health Center of East Central Kansas ("Mental Health Center"). Tr. 301. He reported that his drugs of choice were marijuana and alcohol, which he had last used two weeks earlier. Tr. 302.

On October 20, 2009, plaintiff looked tired and had a scattered thought process and depressed mood and affect. Tr. 413. For the next several months, treatment providers at the Mental Health Center recorded normal findings, except for depressed mood and tired affect on January 5, 2010. Tr. 404, 407, 409, 411. His treating mental health nurse practitioner prescribed Seroquel and Lexapro to treat his depression and other mental health issues.

On June 15, 2010, Philip Rosenshield, Ph.D., a state agency psychologist, opined that plaintiff's psychological impairment was not severe. Tr. 376. On December 22, 2010, Sallye Wilkinson, Ph.D., affirmed Dr. Rosenshield's opinion. Tr. 428.

On July 29, 2010, plaintiff returned to the Mental Health Center, exhibiting a depressed mood and flat affect. Tr. 402. On August 5, 2010, his treating nurse practitioner prescribed Abilify. Two weeks later, he reported that Abilify was not working and that it made him more irritated and upset. Tr. 401.

On March 29, 2011, the Mental Health Center treatment notes indicate that plaintiff was unkempt and displayed a depressed mood. Tr. 552. On July 19, 2011, the Mental Health Center discharged plaintiff because he had stopped going to appointments. Tr. 551.

Spine And Related Physical Conditions

On May 2, 2010, plaintiff injured himself while lifting a truck battery. On May 3, 2010, Jeff Sloyer, M.D., examined plaintiff and observed tenderness between his shoulder blades, a positive ulnar compression test and a positive Tinel sign.[1] Tr. 421. On May 8, 2010, an MRI of plaintiff's cervical spine revealed severe degenerative disc disease between C5 and C6 and between C6 and C7 with some displacement of the cervical cord. Tr. 353. The radiologist recommended referral to a neurosurgeon. Tr. 353.

On June 1, 2010, Dr. Sloyer examined plaintiff and found that he had pain with range of motion, tenderness to palpation and spastic muscle bundles. He prescribed Prednisone and commented that plaintiff "is in the process of getting disability which I think it is a good plan since he is not employable at this time." Tr. 420.

On June 14, 2010, Anthony Eidelman, M.D., a pain management specialist, examined plaintiff. He found that plaintiff had slightly reduced range of motion of his neck, reduced grip strength and decreased sensation in plaintiff's hands. Tr. 356-57. He diagnosed chronic pain, cervical degenerative disc disease, cervical radiculopathy and cervical stenosis. Tr. 357. He administered an epidural steroid injection. Tr. 357. On July 12, 2010, Dr. Eidelman gave plaintiff a second injection. Tr. 397.

On July 9, 2010, Marcia Foster, M.D., a State agency physician, opined that plaintiff could perform light work with no overhead reaching.

On August 9, 2010, Dr. Sloyer reported improved range of motion and pain control with Gabapentin. Tr. 419. On August 25, 2010, Dr. Sloyer prescribed Maxalt, Demerol and Phenergan to help alleviate a migraine. Tr. 418. On September 10, 2010, plaintiff reported that his upper back pain was not controlled. Tr. 432. Dr. Sloyer found pain with range of motion, increased the dose of Gabapentin and referred plaintiff to a neurosurgeon. Tr. 432.

On December 7, 2010, an MRI of plaintiff's cervical spine revealed significant cervical degenerative disc disease and foraminal stenosis at C5 through C7. Tr. 426. On January 17, 2011, Matthew Wills, M.D., a neurosurgeon, examined plaintiff. Tr. 439-440. Dr. Wills noted diminished upper extremity strength, diminished lower extremity sensation and reduced reflexes. Tr. 440. Dr. Wills recommended a three-level cervical fusion. Tr. 440.

On February 5, 2011, Lucas Schnell, M.D., a consultative physician, examined plaintiff and observed reduced range of motion and diminished grip strength bilaterally. Tr. 450.

On February 9, 2011, plaintiff had cervical fusion surgery. Tr. 497. Dr. Wills instructed plaintiff to wear a cervical collar at all times when out of bed. Tr. 534. Two weeks after the surgery, Dr. Wills noted that plaintiff continued to have numbness in his right arm. Tr. 468.

On March 4, 2011, plaintiff fell and went to Stormont-Vail Hospital for treatment. Tr. 471. An examination revealed weakness in the arms and hands. Tr. 472. A CT scan of the cervical spine showed osteophytes between C3 and C6 in addition to foramina narrowing at C5 through C7. Tr. 473.

On April 8, 2011, Dr. Wills removed the cervical collar and directed plaintiff not to work for three months and referred him to physical therapy. Tr. 504-03. On April 19, 2011, an x-ray of plaintiff's hands revealed mild degenerative joint disease. Tr. 600.

On May 4, 2011, Carol Eades, M.D., a state agency physician, opined that plaintiff should be capable of a range of light work with no overhead reaching or depth perception within 12 months of his surgery. Tr. 508-15.

On May 10, 2011, Dr. Sloyer examined plaintiff to evaluate hand pain and numbness. Tr. 584. Dr. Sloyer noted positive Tinel and Phalen signs[2] bilaterally and prescribed wrist splints. Tr. 584. On June 17, 2011, Dr. Sloyer prescribed Gabapentin for lower extremity neuropathy, and suggested that plaintiff wait "to see how his disability or medical card turns out" before pursuing more aggressive treatment. Tr. 583. On September 14, 2011, Dr. Sloyer observed reduced range of motion, stiffness and pain to touch. He prescribed Hydrocodone and Neurontin for pain. Tr. 580.

On December 9, 2011, Dr. Sloyer noted that Dr. Wills recommended injections for plaintiff's pain but that plaintiff was not insured. Tr. 579. Dr. Sloyer examined plaintiff and found that he exhibited decreased range of motion. Specifically, plaintiff could move his neck only 30 to 40 per cent to either side, adduction was more limited and grip strength was weak in the right hand. Plaintiff exhibited radicular symptoms. Tr. 579. Dr. Sloyer opined that plaintiff met Listing 1.04. Dr. Sloyer indicated that plaintiff's condition would require him to walk away from a work station every 15 minutes and that he would miss more than four days of work a month. Tr. 537-540, 546.

On March 24, 2012, a CT scan of plaintiff's cervical spine revealed stable post-surgical changes. Tr. 637.

On September 5, 2012, Dr. Sloyer stated that plaintiff's had degenerative disc disease with stenosis that caused numbness and pain in both arms. Dr. Sloyer suggested that plaintiff's ...

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