Coffey v. SSA
Filing
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OPINION AND ORDER: (1) Pla's 10 Motion for Summary Judgment is DENIED. (2) Dft's 11 Motion for Summary Judgment is GRANTED. (3) Decision of the Commissioner is AFFIRMED pursuant to sentence four of 42 USC 405(g). (4) A judgment will be entered contemporaneously with this order. Signed by Judge Karen K. Caldwell on July 2, 2014. (AWD) cc: COR
.Eastern District of Kentucky
F I LED
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF KENTUCKY
CENTRAL DIVISION
AT LEXINGTON
DARRELL G. COFFEY,
JUL 0 2 2014
AT LEXINGTON
ROBERT R. CARR
CLERK U.S. DISTRICT COURT
CIVIL ACTION NO. 5:13-177-KKC
Plaintiff,
V.
OPINION & ORDER
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.
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The plaintiff, Darrell G. Coffey, brought this action pursuant to 42 U.S.C. § 405(g) to
obtain judicial review of an administrative decision of the Commissioner of Social Security
denying his claim for a period of disability and disability insurance benefits. The Court,
having reviewed the record, will affirm the Commissioner's decision, as it is supported by
substantial evidence.
FACTUAL AND PROCEDURAL BACKGROUND
Coffey filed his claim for benefits on August 16, 2010, alleging a disability beginning on
July 22, 2010. His claim was denied initially on September 29, 2010, and upon
reconsideration on November 15, 2010. He then filed a written request for a hearing before
an Administrative Law Judge ("ALJ"). After the hearing, the ALJ issued an unfavorable
decision on October 3,2011.
At the time of the alleged onset of disability, Coffey was 42 years old and has a limited
education. (AR 20). He claims to be disabled due to a combination of physical and mental
impairments. In his original request for benefits, Coffey claimed he was disabled due to
physical conditions, which included degenerative disc disease, arthritis, high blood
pressure, status post broken right hip, status post head trauma due to a car wreck, and a
torn ligament on his right shoulder. (AR 156). After initially being denied benefits, Coffey
made further claims that he had mood swings, was stressed, and had difficulty
remembering things. (AR 206). Then in a subsequent disability report, Coffey claimed he
was forgetful. (AR 214). But when completing his function report, the only difficulties
Coffey complained of stemmed from neck and back pain. (AR 185-93).
Coffey testified during the administrative hearing that he suffered from depression,
although he had not sought treatment for any mental health problems until shortly before
the hearing, (AR 42-43, 48, 61). To this end, Coffey visited the Health Now Clinic on
August 23, 2011 and obtained a letter from psychiatric nurse practitioner Deborah
Whitehouse. In her letter, Whitehouse stated that the plaintiff reported losing weight, sleep
difficulties, and other symptoms indicative of depression. Whitehouse diagnosed Coffey
with panic disorder and major depressive disorder. (AR 313), This is the only treatment
note from the Health Now Clinic, as Coffey did not seek any treatment for mental health
difficulties until just before his hearing.
The record also indicates that Coffey's prImary physician, Adam Hall, D,O., never
diagnosed him with a mental condition. Dr. Hall's treatment notes indicate that Coffey did
not complain of depression, denied any malaise, and stated he was feeling "generally well"
other than some poor sleeping and chronic neck and low back pain, (AR 244, 246, 248). The
only deviation from these notes is that Coffey indicated to Dr. Hall he had taken a Xanax
from his wife after suffering a loss in his family. (AR 244, 246, 248).
In determining whether a claimant has a compensable disability under the Social
Security Act (the "Act"), the regulations provide a five-step sequential process which the
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ALJ must follow. 20 C.F.R § 404.1520(a)-(e); see Walters v. Comm'r of Soc. Sec., 127 F.3d
525, 529 (6th Cir. 1997). The five steps, in summary, are as follows:
(1) If the claimant is currently engaged in substantial gainful activity, she is not
disabled.
(2) If the claimant is not doing substantial gainful activity, her impairment must be
severe before she can be found disabled.
(3) If the claimant is not doing substantial gainful activity and is suffering from a
severe impairment that has lasted or is expected to last for a continuous period of at
least twelve months, and his impairment meets or equals a listed impairment, the
claimant is presumed disabled without further inquiry.
(4) If the claimant's impairment does not prevent her from doing past relevant work,
she is not disabled.
(5) Even if the claimant's impairment does prevent her from doing past relevant work,
if other work exists in the national economy that accommodates her residual
functional capacity and vocational factors (age, education, skills, etc.), she is not
disabled.
ld.
The burden of proof is on the claimant through the first four steps of the process to
prove that she is disabled. Bowen v. Yuckert, 482 U.s. 137, 146, n. 5 (1987). If the ALJ
reaches the fifth step without finding that the claimant is not disabled, then the burden
shifts to the Commissioner to consider the claimant's residual functional capacity, age,
education, and past work experience to determine if she could perform other work. If not,
she would be deemed disabled. 20 C.F.R 404.1520(f). Importantly, the Commissioner only
has the burden of proof on "the fifth step, proving that there is work available in the
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economy that the claimant can perform." Her v. Comm'r of Soc. Sec., 203 F.3d 388,391 (6th
Cir. 1999).
In this case, the ALJ began his analysis at step one by determining that the claimant
has not engaged in gainful activity since July 22, 2010, the alleged onset date. (AR 16). At
step two, the ALJ determined that Coffey suffers from the following severe impairments:
degenerative disc disease of the lumbar spine with chronic back pain, and degenerative disc
disease of the thoracic spine. (AR 16). In the third step, the ALJ found the claimant does
not have an impairment or combination of impairments that meets or medically equals the
severity of one of the listed impairments. (AR 17).
At step four, the ALJ found that based on consideration of the entire record including all
medically determinable evidence, Coffey "has the residual functional capacity to perform
light work as defined in 20 CFR. 404.1567(b) and 416.967(b)." The ALJ further found that
Coffey can "perform light work activities with occasional lifting and carrying 20 pounds and
frequently 10 pounds; stand and walk a total of six hours in an eight-hour workday; sit a
total of six hours in an eight-hour workday; no more than frequent pushing and pulling or
use of hand control with bilateral upper extremities; only occasional climbing stairs and
ladders and never ladders [sic], ropes and scaffolds; only occasional stooping, kneeling,
crouching or crawling." (AR 17). Finally, the ALJ found that Coffey "should avoid
concentrated exposure to full body vibration." (AR 17). Under this RFC, the ALJ
determined, with the aid of a vocational expert, that Coffey was able to perform past
relevant work as a battery assembler. (AR 20).
Although the ALJ concluded that Coffey could perform past relevant work, he went on
to step five and determined that, as an alternative finding, there are other jobs that exist in
significant numbers in the national economy that the claimant can perform. (AR 20). This
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conclusion was based on consideration of the claimant's age, education, work experience,
and residual functional capacity as well as the testimony of the vocational expert. (AR 20
21).
The Appeals Commission subsequently denied Coffey's request for review on May 1,
2013. Coffey has exhausted his administrative remedies and filed a timely action in this
Court. This case is now ripe for review under 42 U.S.C. § 405(g).
GENERAL STANDARD OF REVIEW
The decision of the Commissioner must be supported by substantial evidence. Varley v.
Sec'y 0/ Health and Human Servs., 820 F.2d 777, 779 (6th Cir. 1987). Once the decision of
the Commissioner
final, an appeal may be taken to the United States District Court
pursuant to 42 U.S.C. § 405(g). Judicial review of the Commissioner's decision is restricted
to determining whether it is supported by substantial evidence and was made by proper
legal standards. See Cullip v. Sec'y
0/ Health and Human Servs., 25 F.3d 284, 286 (6th Cir.
1994). "Substantial evidence" is defined as "more than a scintilla of evidence but less than a
preponderance; it is such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion." Id. In reviewing the decision of the Commissioner, courts are not
to conduct a de novo review, resolve conflicts in the evidence, or make credibility
determinations. See id. Rather, the Court must affirm the Commissioner's decision so long
as it is supported by substantial evidence, even if the Court might have decided the case
differently. See Her, 203 F.3d at 389-90. However, the Court must review the record as a
whole, and must take into account whatever in the record fairly detracts from its weight.
Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984).
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ANALYSIS
Coffey contends that the ALJ committed two general errors in determining the
severity of his impairments. First, he states that the ALJ "erred as a matter of law in
finding that the Plaintiffs depression and panic disorder were non-severe impairments, and
he failed to properly evaluate [Coffey's] claims of disabling pain." (DE 10, at 5). Second,
Coffey argues that the ALJ failed to fully develop the record. The Court will address these
claims in turn.
1. The ALJ's Evaluation of Coffey's Alleged Impairments Is Supported By
Substantial Evidence
Coffey contends that the ALJ erred in his "failure to find the depression, panic disorder
and illiteracy to be severe impairments." (DE 10, at 9). Coffey points to several places in the
record he believes sufficiently established that these alleged impairments are severe
including:
• A visit to the Doctor's Pain Management and Injury Center
on November 16, 2010, where he was prescribed Xanax and
Soma;
• A prescription from his family doctor in January 2009 for
Xanax;
• A visit with psychiatric nurse practitioner Deborah
Whitehouse during which Ms. Whitehouse stated that Coffey
lost 30 pounds within the last six months and had significant
sleep problems;
• Ms. Whitehouse diagnosing Coffey with major depressive
disorder and panic disorder and recommendation that he
restart his Xanax;
• Coffey's testimony during the hearing that he believed panic
and depression were severe problems in his life affecting sleep
and ability to engage in activities; and
• Coffey's testimony during the hearing that he cannot read or
write.
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(DE 10, at
5~7).
A claimant's "symptoms, such as pain, fatigue, shortness of breath, weakness, or
nervousness, will not be found to affect your ability to do basic work activities unless
medical signs or laboratory findings show that a medically determinable impairment(s) is
present." 20 C.F.R. §§ 404. 1529(b), 416.929(b). An impairment is not severe if it does not
significantly limit a claimant's ability to do basic work activities. 20 C.F.R. §§ 404.1521 (a);
416.921(a). Moreover, "statements about your pain or other symptoms will not alone
establish that you are disabled; there must be medical signs and laboratory findings which
show that you have a medical impairment(s) which could reasonably be expected to produce
the pain or other symptoms alleged and which, when considered with all of the other
evidence ... would lead to a conclusion that you are disabled." 20 C.F.R. §§ 404. 1529(a);
416.929(a).
The ALJ determined that "[t]here is no evidence of a medically determinable mental
impairment. The claimant alleges he has a difficult time focusing and remembering;
however, there is scant evidence of record." (AR 19). This finding is supported by the
substantial evidence. Coffey did not list any mental impairments on his application for
benefits, and described pain as the only limiting impairment in his own description of his
functional capacity. (AR 185-93). His claim of panic disorder and depression arose only
right before his hearing before the ALJ, and he shows no history of ever having been
treated for mental health problems. And although Coffey contends that this was due to
limited financial means, treatment notes from his primary care physician Dr. Hall indicate
that he had no reportable mental health problems. (AR 244--52) (indicating normal mental
health).
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The only evidence that Coffey relies on to demonstrate a mental health impairment is
his own testimony, one visit to a psychiatric nurse practitioner where she diagnosed him
with depressive disorder and panic disorder, and a prescription for Xanax. None of this
necessarily indicates an impairment. See Young v. Sec'y of Health & Human Servs., 925
F.2d 146, 151 (6th Cir. 1990) ("This court has determined that a claimant must do more to
establish a disabling mental impairment than merely show the presence of a dysthymic
disorder."). Whitehouse did not conduct any clinical or psychological tests to determine
whether Coffey is impaired.
The ALJ correctly noted that Coffey has not presented any medical evidence
demonstrating he has a mental health condition arising to the level of impairment. The fact
that he has received a prescription for Xanax, in the past, and had a psychiatric nurse
practitioner diagnose him with depressive disorder and panic disorder l is not enough. See
20 C.F.R. §§ 404.1513(a), 416.913(a) (indicating that a nurse practitioner is not an
acceptable medical source for establishing an impairment). The ALJ's determination that
Coffey does not suffer from a mental health impairment is supported by substantial
evidence in the record. See Moon v. Sullivan, 923 F.2d 1175, 1182 (6th Cir. 1990)
(explaining that a claimant must demonstrate his mental health impairment with "medical
evidence consisting of clinical signs, symptoms and/or laboratory or psychological test
findings") (quoting 20 C.F.R. Pt. 404, Subpt. P, App. 1). Accordingly, the ALJ did not need
to account for any mental limitations in determining Coffey's RFC, and no error was made.
Coffey also contends that the ALJ erred in failing to consider his complaints of neck
pain and illiteracy. (DE 10, at 5-7, 9). But Coffey fails to develop these arguments with any
1 Notably. Coffey relies heavily on the note by APRN Deborah Whitehouse, such as when he stated
that he had lost thirty pounds in the last six months and had significant sleep disorders. But
Whitehouse notes only the information that Coffey related to her. See AR 313 ("He reports a loss of
30 Ibs in the last six months. He has severe pain and sleep disturbance.").
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particularity. This court will not "formulate arguments on [Coffey's] behalf, or [] undertake
an open-ended review of the entirety of the administrative record to determine (i) whether
it might contain evidence that arguably is inconsistent with the Commissioner's decision,
and (ii) if so, whether the Commissioner sufficiently accounted for this evidence." Hollon ex
rel. Hollon u. Comm'r of Soc. Sec., 447 F.3d 477,490-91 (6th Cir. 2006).
As to the alleged error regarding neck pain, Coffey makes only a passing remark in his
brief without providing any support as to how the ALJ erred. The ALJ discussed Coffey's
neck pain and determined that it did not impose a significant limitation on his ability to
work. (AR 18-19). Coffey's general claim that the ALJ erred by failing to consider his neck
pain lacks merit, and the Court will not take it upon itself to conduct an exhaustive review
of the record to determine, on Coffey's behalf, whether any specific errors were made.
Similarly, although Coffey repeatedly states that the ALJ erred when he failed to find
his panic disorder and depression severe impairments, Coffey makes only brief remarks
about illiteracy. He states that during the hearing Coffey discussed being illterate and
includes illiteracy within a conclusory recitation of the ALJ's errors (arguing that the ALJ
erred when he "fail[ed] to find the depression, panic disorder and illiteracy to be severe
impairments"). (DE 10, at 7, 9). Like his references to neck pain, Coffey never points to
objective evidence demonstrating the ALJ's error, and perhaps more significantly, never
addresses the inconsistency in his ability to fill out his paperwork despite being illiterate.
For the above-stated reasons, the ALJ did not commit error in determining that his
mental impairments and neck pain were not severe impairments, and the ALJ's finding is
supported by the substantial evidence.
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2. The ALJ Did Not Fail to Fully Develop the Record
Coffey's second alleged error is that the ALJ failed to fully develop the record. An ALJ
must conduct a full inquiry, but a "[fJull inquiry does not require a consultative
examination at government expense unless the record establishes that such an examination
is necessary to enable the [ALJ] to make the disability decision." Landsaw v. Sec'y of Health
& Human Servs., 803 F.2d 211, 214 (6th Cir. 1986) (internal quotations omitted). The
decision to order further consultative examinations is within the discretion of the ALJ, 20
C.F.R. §§ 404.1517, 416.917, and the regulations "simply grant [the ALJ] the authority to
[refer a claimant to a consultative specialist] if the existing medical sources do not contain
sufficient evidence to make a determination." Id. (noting that an ALJ is not required to
order a consultative exam). In this case, the ALJ did not have a duty to develop the record
any further with regard to Coffey's alleged mental impairments, as the record was void of
any evidence that Coffey suffered from a mental impairment impacting his ability to do
work. See Ball v. Sec'y of Health and Human Servs., 931 F.3d 893, 1991 WL 66051, at *4
(6th Cir. 1991) (unpublished). Additional consultative examinations are not necessary when
nothing in the record indicates that the claimant's residual functional capacity is affected
by an impairment and the claimant himself has failed to allege it. Id. Accordingly, the ALJ
did not abuse his discretion in rejecting Coffey'S request for psychological consultations.
In addition to the psychological examinations, Coffey contends the ALJ abused his
discretion in rejecting his request for an all-systems exam. During the hearing, the ALJ
rejected the request because Coffey already had a recent MRI on the record and he did not
believe another one would necessary. The ALJ explained that the MRI's address the issues
Coffey complains of and "they're pretty determinative of what the problem is." (AR 31).
Coffey contends that the ALJ "play[ed] doctor" when he determined that the medical record
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was sufficient, but this is exactly the kind of finding the ALJ is required to make. See 20
C.F.R. §§ 404. 1545(a)(3); 41B.945(a)(3) (explaining that the ALJ is responsible for
determining when consultative examinations might be necessary to develop the record).
Moreover, Coffey offers the Court no specific reason as to why the evidence on the record
was insufficient. He instead states that "[a]lmost every single disability claim results in a
consultative examination for evaluation purposes," and wonders why his case should be any
different. (DE 10, at 12). To suggest that an ALJ should order consultative exams based on
an anecdotal aggregation of other cases defies logic: it is the responsibility of the ALJ to
determine what is necessary in this case, which is unrelated to what might have been
necessary in other cases. The ALJ did not err in rejecting the claim for additional
consultative exams, and his decision in denying Coffey's claim for benefits is supported by
substantial evidence in the record.
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For the reasons stated above, IT IS ORDERED that:
1. The plaintiffs motion for summary judgment (DE 10) is DENIED;
2. The defendant's motion for summary judgment (DE 11) is GRANTED;
3. The decision of the Commissioner is AFFIRMED pursuant to sentence four of 42
U.S.C. § 405(g) as it was supported by substantial evidence and was decided by
proper legal standards; and
4. A judgment will be entered contemporaneously with this order.
Dated this 2nd day of July, 2014.
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