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Stone v. Berryhill

United States District Court, S.D. Indiana, Indianapolis Division

March 27, 2018

BRIAN D. STONE, Plaintiff,
NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.


          TANYA WALTON PRATT, JUDGE United States District Court.

         Plaintiff Brian D. Stone (“Stone”) requests judicial review of the final decision of the Commissioner of the Social Security Administration (the “Commissioner”), denying his application for Social Security Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (the “Act”). For the following reasons, the Court AFFIRMS the decision of the Commissioner.

         I. BACKGROUND

         A. Procedural History

         On November 6, 2013, Stone filed an application for DIB, alleging a disability onset date of July 1, 2012, which he later amended to July 16, 2013, due to his Crohn's disease, back pain, obesity, anxiety, and depression. The claim was initially denied on January 22, 2014, and again on reconsideration on March 12, 2014. Stone filed a written request for a hearing on March 17, 2014.

         A hearing was held before Administrative Law Judge John H. Metz (the “ALJ”) on August 31, 2015. Stone was present and represented by counsel, Michael G. Myers. Medical experts, Mark O. Farber, M.D. (“Dr. Farber”), and James Brooks, Ph.D., testified at the hearing. Michael L. Blankenship, a vocational expert, also appeared and testified at the hearing. On September 10, 2015, the ALJ denied Stone's application for DIB. Following this decision, on October 1, 2015, Stone requested review by the Appeals Council. On October 26, 2016, the Appeals Council denied Stone's request for review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. On December 30, 2016, Stone filed this action for judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g).

         B. Factual Background

         At the time of his amended alleged disability onset date, Stone was forty-six years old, and he was forty-nine years old at the time of the ALJ's decision. Stone is now fifty-one years old. He attended formal schooling through the eleventh grade, but he did not complete his high school education and did not earn a GED. Prior to the onset of his alleged disability, Stone worked as a tile setter and a landscaper.

         The administrative record contains relatively few medical records and shows limited treatment was sought by Stone for his various impairments. He went to the hospital on January 21, 2010, because he was experiencing lower back pain. Stone underwent an MRI of his lumbar spine, which revealed mild to moderate degenerative changes with some disc bulges, disc space narrowing, and central stenosis (Filing No. 13-7 at 4-5). During the month of March 2010, he participated in approximately six sessions of physical therapy to strengthen his back and alleviate his pain (Filing No. 13-7 at 7-18).

         More than three years later and soon after Stone had filed his application for DIB, on November 26, 2013, Andrew J. Koerber, M.D. (“Dr. Koerber”), performed a consultative examination on Stone. He reported to Dr. Koerber that he had Crohn's disease and lower back pain. He also reported that his back pain started in 2007 or 2008 and got progressively worse in 2010. Stone reported that he had been seen by spinal surgeons and pain management specialists, but he never had surgery because the surgeons thought surgery would not be helpful. He noted trying physical therapy but said that it caused more pain. He also reported having some spinal injections, which provided limited relief, and receiving chiropractic manipulations. Stone explained that his back pain caused him to have depression, and his pain is worse when he is sitting, standing, or walking. He also discussed with Dr. Koerber his Crohn's disease symptoms and his limited past treatment that had not been helpful. He noted a colonoscopy that he received in January 2011, which revealed polyps and Crohn's disease (Filing No. 13-7 at 42-43).

         During the examination with Dr. Koerber, Stone reported that he could walk about one hundred feet, stand for five minutes, sit for five minutes, and lift about three pounds. The physical examination revealed decreased range of motion in the lumbar spine and shoulders with decreased supination in his left elbow, but with no other limitations in the upper and lower extremities. Dr. Koerber's examination also revealed tenderness in Stone's lower back. His strength in his extremities was normal at 5/5. Despite Stone's complaints of pain, Dr. Koerber noted that Stone was in no acute distress and demonstrated a normal gait and posture. He also could ambulate around the room at a normal pace without holding onto the wall, and he could get on and off the examination table without difficultly. Stone was not able to tandem walk, toe or heel walk, or perform a knee squat. Id. at 43-45. Dr. Koerber noted that Stone did not need a cane or walker to ambulate. Dr. Koerber provided a medical source statement, opining that Stone could sit, stand, and move about for short periods and lift and carry fifteen pounds, but he would have difficulty kneeling/squatting. Id. at 45-46.

         On December 27, 2013, x-rays of Stone's lumbar spine and shoulders were taken. The x-rays revealed some mild to moderate disc degeneration and mild lower lumbar facet arthritis. They also revealed mild osteoarthritis in both shoulders (Filing No. 13-8 at 31). A comprehensive metabolic laboratory test also was performed on December 27, 2013. The test revealed low alanine and aspartate transaminase levels, but all other levels were within normal range (Filing No. 13-8 at 27).

         On June 24, 2014, Denise Bland, M.D. (“Dr. Bland”), provided a medical statement regarding Stone's physical abilities and limitations. Dr. Bland opined that Stone could stand/walk for fifteen minutes at a time for a total of sixty minutes in a workday. She opined that Stone could sit for fifteen minutes at a time for a total of two hours in a workday. He could occasionally lift five pounds and frequently lift less than five pounds. She opined that he could rarely bend or stoop and only occasionally balance. Dr. Bland opined that Stone suffered from severe pain and would need to elevate his legs during an eight-hour workday. She noted that his pain would frequently interfere with his attention and concentration, and it was likely that he would miss more than four days of work each month. Dr. Bland's opinion did not include any reference to clinical, objective, or laboratory testing or findings (Filing No. 13-8 at 50).

         Stone saw Rachael Sanchez, N.P. (“Nurse Sanchez”), on December 31, 2014, with complaints of back pain radiating into his right leg as well as depression. He was using a cane. Stone rated his pain as 10/10 on the pain scale, but Nurse Sanchez noted that he was in no distress. Nurse Sanchez's physical examination revealed a decreased range of motion and tenderness in Stone's lower back, and he was prescribed medication for nerve pain and was referred to a spine center for further treatment (Filing No. 13-8 at 62-63). On June 23, 2015, Stone again met with Nurse Sanchez because of his back pain. He noted his previous physical therapy and steroid injections that did not provide relief. Nurse Sanchez again prescribed medication and referred him for an MRI and possible neurosurgery. Id. at 56-57. An August 26, 2015 MRI of Stone's lumbar spine revealed degenerative changes with some disc bulges, disc space narrowing, and neuroforaminal narrowing. Id. at 70-71.

         Regarding Stone's mental health impairments, the medical record indicates that on March 24, 2013, Stone was taken by the police to Community Hospital for crisis intervention after a fight with his girlfriend. At the hospital, Stone reported a history of mood swings secondary to marijuana use. He also reported a history of anger issues. Stone was diagnosed with a general mood disorder and assigned a global assessment of functioning (“GAF”) score of 45. He was not admitted to the hospital ...

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