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Caviness v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

March 31, 2017

BENJAMIN CAVINESS, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION AND ORDER

          JON E. DEGUILIO Judge United States District Court

         In this case, plaintiff Benjamin Caviness, by counsel, appeals the denial of his claim for Social Security Disability Insurance Benefits. For the following reasons, the Court remands this matter to the Commissioner for further proceedings consistent with this opinion.

         I. FACTUAL BACKGROUND

         A. Procedural Background

         Caviness sought disability insurance benefits on July 21, 2014, alleging an onset date of April 1, 2007. (Tr. 253-61). Caviness indicated that he was unable to work due to back pain, anxiety, depression, and post-traumatic stress disorder ("PTSD"). (Tr. 269-94). Because Caviness remained insured through December 31, 2012, he had to establish disability on or before that date in order to be entitled to the benefits he sought. But his application was denied initially and on reconsideration. (Tr. 188, 195). An Administrative Law Judge ("ALJ") held a hearing on March 30, 2015, during which Caviness appeared with counsel and testified, along with a vocational expert ("VE") who testified. (Tr. 129-81). On April 21, 2015, the ALJ decided that even though Caviness suffered from the severe impairments of degenerative disc disease, obesity, depression, anxiety, and PTSD, he could still perform light work that was limited (in relevant part) to simple routine tasks that were not performed at a production rate pace and involved no more than occasional changes in the work setting. (Tr. 111-22). The ALJ did not impose any further mental or social restrictions, such as limiting the amount of interaction with coworkers, supervisors, or the public. The hypotheticals posed to the VE considered the same limitations (which were ultimately contained in Caviness' assigned residual functional capacity ("RFC")[1]), and the VE testified that such a restricted individual could still perform work as an office helper, mail clerk, house cleaner, order clerk, charge account clerk, and information clerk. Thus, the ALJ determined that Caviness was not disabled through December 31, 2012, since he could perform these other jobs.

         On July 17, 2015, the Appeals Council denied Caviness' request for review of the ALJ's decision, stating that "[w]e found no reason under our rules to review the Administrative Law Judge's decision." (Tr. 1). The Appeals Council wrote:

We also looked at the following materials that you submitted to us (1) medical records of the VA Hospital dated from January 2, 2015 to January 15, 2015 (3 pages), (2) a VA Benefits Decision dated May 12, 2015 adjusting your disability rating effective May 15, 2014 (7 pages), (3) a VA Benefits Summary dated May 14, 2015 (3 pages), and (4) medical records of VAMC Marion dated from February 14, 2015 to May 14, 2015 (79 pages). The Administrative Law Judge decided your case through December 31, 2012, the date you were last insured for disability benefits. This new information is about a later time. Therefore, it does not affect the decision about whether you were disabled at the time you were last insured for disability benefits.

(Tr. 2). Caviness filed a timely complaint seeking judicial review of the Commissioner's decision, and this Court has jurisdiction pursuant to 42 U.S.C. § 405(g). Caviness specifically contends that a remand for further proceedings is necessary because the Commissioner erred as a matter of law in denying Caviness' claim when the Appeals Council did not apply its regulation properly in considering "new" and "material" evidence which revealed that Caviness was further limited in his mental and social ability to perform other work. Caviness further suggests that the Commissioner's decision is ultimately not based on substantial evidence.

         B. Medical Background

         Caviness was born on March 6, 1978, and is currently 39 years old. (Tr. 269). Caviness was enlisted in the Army for four years as a patient administrative specialist (taking care of the paperwork for births, deaths, and air evacs), until he injured his back when a large steel desk fell and trapped him on the floor. (Tr. 142, 168). Following his service overseas, he was basically unable to maintain regular employment due to the physical and mental demands of regular work. But because Caviness does not challenge the ALJ's assessment of his physical limitations, the Court turns to his documented mental limitations.

         During the administrative hearing, the ALJ questioned Caviness about why he felt he could not work, referring to the period before December 2012. Caviness responded that his "physical disabilities aside, " his anxiety caused great limitations. (Tr. 149-50). Caviness discussed his hypervigilance and noted that he was "freaked out" by having to appear at the disability hearing because there was only one way in and one way out of the building. (Tr. 150). He testified that his constant pain and other physical ailments caused him to be mean and the thought of dealing with people gave him anxiety. (Tr. 150-51). After the ALJ noted the record's supporting diagnoses for anxiety and depression, with PTSD "definitely [being] mentioned in the record throughout the years, " the ALJ asked Caviness to discuss how his mental problems affected him on a daily basis. (Tr. 158). At that point, Caviness explained how he conducts perimeter checks of his house and is constantly on the lookout for threats and exits. (Tr. 158-60).

         Caviness referenced having nightmares, even with the help of medication, and noted that his sleep suffered as a result. Id. Caviness also noted having issues with his concentration, as well as anxiety attacks on a daily basis caused by his fear of situational events. (Tr. 161). It was Caviness' opinion that his anxiety, depression, and PTSD were all "tied in together." (Tr. 159).

         Caviness' mental health treatment records indicate that in July 2009 he requested mental health counseling after experiencing dreams and flashbacks from his military tour. (Tr. 557-59). On September 23, 2009, Caviness presented to Dr. Sarah Higley for a psychological consult, specifically for a PTSD screening and comprehensive psychiatric evaluation. (Tr. 546-56). Caviness relayed high levels of stress and flashbacks to his tour of duty. Id. On mental exam, Dr. Higley noted no abnormalities and indicated that although Caviness was referred for an evaluation due to reported symptoms of PTSD, when evaluated, Caviness was unable to provide details about specific military-related incidents that were distressing and he did not report any symptoms consistent with PTSD. Id. Dr. Higley diagnosed unspecified adjustment disorder and cannabis abuse. Id. Again, in November 2009, January, March, April, and October 2010, Caviness presented with reports of stress, but noted that it was mostly attributed to situational factors. (Tr. 520-44). No new clinical findings or diagnoses were noted. Id.

         Just after his date last insured, Caviness sought treatment again in early 2013 with complaints of PTSD. (Tr. 450-53, 458). During a psychiatric evaluation performed by Dr. Echo Arnett, Caviness complained of volatile mood and poor sleep. Id. On exam, Dr. Arnett noted Caviness as having poor insight and judgment, behavioral control issues, inability to tolerate criticism, and impulsiveness. Id. Dr. Arnett diagnosed Caviness with anxiety disorder NOS, depressive disorder NOS, and personality disorder NOS with narcissistic/borderline features. Id.

         Despite inclusion in Caviness' administrative medical record, the ALJ did not discuss the following medical records concerning Caviness' ongoing mental problems:

         Mainly, on August 8, 2013, Caviness presented to Jonathan Graber, NP, for an updated comprehensive psychiatric exam, including medication review and supportive therapy. (Tr. 439-41). Caviness reported being irritable and short tempered, as well as experiencing feelings of hopelessness and depression, panic attacks, visual hallucinations of dead babies, poor motivation, flashbacks, and changing appetite. Id. It was noted that Caviness was "looking for medications for anxiety and depression" and that he had "been hesitant to try to get help in the past." Id. Mr. Graber diagnosed Caviness with depression NOS, anxiety NOS, and ...


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