United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
Christopher A. Nuechterlein United States Magistrate Judge.
On June 13, 2014, Plaintiff Henderson Trusty (“Trusty”), proceeding pro se, filed his complaint in this Court seeking reversal of Defendant Acting Commissioner of Social Security’s (“Commissioner”) determination that Trusty was no longer disabled as of June 1, 2011. On October 10, 2014, Trusty filed his opening brief contesting the ALJ’s determination that he was no longer disabled. On February 5, 2015, the Commissioner filed a response requesting that the Court affirm the Commissioner’s decision. Trusty filed no reply brief. This Court may enter a ruling in this matter based on the parties’ consent. 28 U.S.C. § 636(c); 42 U.S.C. § 405(g).
I. Relevant background
Trusty applied for and was awarded disability insurance benefits (“DIB”) as of January 31, 2005,  which is the comparison point decision for purposes of Trusty’s instant complaint (Doc. No. 11 at 107). In that determination, the Commissioner found that Trusty was disabled as of July 1, 2004 (Doc. No. 11 at 21). The Social Security Administration (“SSA”) subsequently conducted a required periodic review of the 2005 disability determination. See 20 C.F.R. § 404.1589. On June 13, 2011, the SSA determined that as of June 1, 2011, Trusty was no longer disabled (Doc. No. 11 at 21, 88). An Administrative Law Judge (“ALJ”) held a hearing regarding Trusty’s disability status on February 25, 2013, and affirmed the determination in a March 22, 2013, opinion (Doc. No. 11 at 21-34).
Trusty was born on July 19, 1966, and was a forty-six-year-old male at the time the ALJ determined he was no longer disabled (Doc. No. 11 at 177). He attended high school, but did not graduate (Doc. No. 11 at 58). Trusty performed past relevant work as a salvage operator (Doc. No. 11 at 43).
A. 2005 Disability Finding
SSA’s 2005 finding that Trusty was disabled was based on his treatment record and the opinions of State agency medical experts. Trusty was twice hospitalized for mental health problems (Doc. No. 11 at 243-51). During a 2003 hospitalization at Eastern State Hospital in Lexington, Kentucky, Trusty was diagnosed with psychotic disorder, not otherwise specified (Doc. No. 11 at 246). Trusty was discharged after his condition improved with medication (Id.). During a subsequent 2004 hospitalization at Eastern State Hospital and the University of Kentucky Medical Center, Trusty was diagnosed with alcohol dependence; alcohol withdrawal (resolved); and psychotic disorder, not otherwise specified (Doc. No. 11 at 243-44, 250). Dr. Rami Kahwash’s consultative medical examination report from December 12, 2004, indicated that Trusty’s complaints of back and ankle pain were likely due to a mild degree of arthritis (Doc. No. 11 at 256).
Based on the opinions of a State agency psychologist, a consulting mental health expert, and Trusty’s medical records, the SSA determined Trusty had the following medically determinable impairments as of January 31, 2005, as listed in 20 C.F.R. Part 404, Subpart P, Appendix 1: Schizophrenic, Paranoid and Other Psychotic Disorders and Substance Addiction Disorders (Doc. No. 11 at 23, 269). Trusty’s specific diagnosis was psychotic disorder, not otherwise specified within the Schizophrenic, Paranoid and Other Psychotic Disorders category (Doc. No. 11 at 66, 271). As a result of these impairments, Trusty was found unable to sustain the concentration, pace, and persistence and social behavior necessary for a normal workday/workweek (Doc. No. 11 at 23). During the original disability application process, a consulting physician also reported that Trusty’s claims of ankle and back pain “might be due [to] a mild degree of arthritis” and that he suffered from uncontrolled hypertension (Doc. No. 11 at 256).
B. Medical Evidence Regarding Disability Review
The SSA subsequently undertook a periodic review of Trusty’s disability status. Trusty stridently argued that he remained disabled, claiming that he was limited by a slipped disc in his lower back, an enlarged heart, and right ankle problems (Doc. No. 11 at 189, 197).
A May 2011 consultative physical examination with Dr. Randall Coulter revealed some pain with palpation over Trusty’s lumbar spine; slightly decreased range of motion in his lumbar spine; slight pain with palpation of right ankle; and minimally limited range of motion in his ankle (Doc. No. 11 at 289). Dr. Coulter reported that Trusty may have some difficulty with lifting, bending, twisting, prolonged standing and prolonged ambulating, but his vision and hearing were good, he communicated well, he had good muscle strength and grip strength, and he was able to perform fine and gross movements (Id.).
Pulmonary testing in September 2012 showed normal major airflow rates and normal diffusion, but a reduction of small airway function, which improved with bronchodilators (Doc. No. 11 at 349). A September 2012 echocardiogram indicated that Trusty had normal left ventricular systolic performance with an estimated ejection fraction of seventy to seventy-five percent, moderate concentric left ventricular hypertrophy, diastolic dysfunction, evidence of mild pulmonary hypertension with right ventricular systolic pressure estimated at forty mmHg, and no significant pericardial effusion (Doc. No. 11 at 352).
Due to the minimal nature of Trusty’s treatment record, the ALJ obtained testimony from an impartial medical expert, Dr. Malcolm Brahms (Doc. No. 11 at 27-28). Dr. Brahms testified that the record revealed that Trusty’s physical impairments were morbid obesity and chronic obstructive pulmonary disease (COPD) (Doc. No. 11 at 62). Dr. Brahms further testified that Trusty complained of low back pain and right ankle pain and that there were some degenerative changes in the ankle joint, but that there was no evidence of any significant joint problems (Doc. No. 11 at 62-63).
C. Disability Review
The SSA’s periodic review closed with the determination that Trusty was no longer disabled. Trusty appealed the ruling and, after a hearing, an ALJ issued a written decision reflecting the following findings based on the eight-step continuing disability review process prescribed by the SSA’s regulations for determining continued disability. See 20 C.F.R. § 404.1594.
At Step One, the ALJ found that Trusty had not engaged in substantial gainful activity through June 1, 2011, the date the claimant’s disability ended (Doc. No. 11 at 23). At Step Two, the ALJ found that through June 1, 2011, Trusty did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (Doc. No. 11 at 24).
At Step Three, the ALJ found that medical improvement occurred because Trusty was originally awarded DIB based on a decrease in the medical severity of the impairments present at the time of the comparison point decision (Doc. No. 11 at 27). In making that determination, the ALJ gave significant weight to the opinion of psychologist Dr. Larry Kravitz, an impartial expert who testified that the medical record indicated that Trusty experienced medical improvement between 2004 and 2011 (Doc. No. 11 at 67). Dr. Kravitz further testified that there was no evidence of any significant mental impairment in those seven years (Id.). Although, Dr. Kravitz did diagnose Trusty with borderline intellectual functioning and alcohol abuse in partial remission (Doc. No. 11 at 68). The ALJ also noted that State agency psychiatric consultants Dr. Donna Unversaw and Dr. J. Gange both opined that Trusty appeared capable of unskilled work, indicating medical improvement (Doc. No. 11 at 298, 332). The ALJ further observed that psychiatric consultant Dr. Alan Wax’s opinion that Trusty’s cognitive functioning appeared to be in the low-average or high-borderline range did not support greater limitations than those outlined in the ALJ’s RFC (Doc. No. 11 at 29, 295). The ALJ also noted that the record lacks any evidence of individualized psychiatric treatment or hospitalizations following the comparison point decision (Doc. No. 11 at 29). Finally, the ALJ observed that Trusty informed Dr. Wax that he was able to undertake basic daily activities, indicating that he cooked, shopped, washed the dishes, did the laundry, took out the trash, and related to friends (Doc. No. 11 at 29, 294).
At Step Four, the ALJ determined that Trusty’s medical improvement was related to his ability to work because it decreased the limitations included in Trusty’s residual functional capacity (RFC) (Doc. No. 11 at 32). Because the ALJ determined that Trusty experienced medical improvement and the medical improvement was related to the ability to work, Step Five is irrelevant and the analysis proceeded to Step Six. 20 C.F.R. 404.1594(f)(4). At Step Six, the ALJ determined that Trusty continued to have a severe impairment or combination of impairments that caused more than minimal limitation of his ability to perform basic work activities as of June 1, 2011 (Doc. No. 11 at 32). The ALJ identified Trusty’s severe impairments as COPD, borderline intellectual functioning, morbid obesity, and a history of alcohol dependence in remission (Doc. No. 11 at 23). The ALJ based this finding on the testimony of Dr. Brahms and Dr. Kravitz; the reports from Dr. Coulter, Dr. Unversaw, and Dr. Gange’s consultative examinations; the opinion of Dr. Wax; and the reports of two State agency physicians, Dr. M. Ruiz and Dr. ...