United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
KATHLEEN B. BURKE, MAGISTRATE JUDGE
Everett Casebolt (“Plaintiff” or
“Casebolt”) seeks judicial review of the final
decision of Defendant Commissioner of Social Security
(“Defendant” or “Commissioner”)
denying his application for Supplemental Security Income
(“SSI”) benefits. Doc. 1. This Court has
jurisdiction pursuant to 42 U.S.C. § 405(g). This case
is before the undersigned Magistrate Judge pursuant to the
consent of the parties. Doc. 12. As explained more fully
below, the Court AFFIRMS the
December 24, 2013, Casebolt protectively filed an application
for Supplemental Security Income
(“SSI”). Tr. 15, 162-167. He initially alleged a
disability onset date of April 1, 1997 (Tr. 15, 162), but
later amended his alleged onset date to October 3, 2013 (Tr.
15, 34, 168). Casebolt alleged disability due to head trauma,
head pain, blurred vision, headaches, memory loss, hernia in
stomach, and ADD. Tr. 55, 81, 113, 183, 222. Casebolt's
application was denied initially and upon reconsideration by
the state agency. Tr. 64, 96, 113-117. Thereafter, he
requested an administrative hearing. Tr. 118-120. On January
7, 2016, Administrative Law Judge Peter Beekman
(“ALJ”) conducted an administrative hearing. Tr.
March 14, 2016, decision (Tr. 12-31), the ALJ dismissed
Casebolt's DIB claim in light of Casebolt's decision
to withdraw his DIB application (Tr. 15-16). With respect to
Casebolt's SSI claim, the ALJ determined that Casebolt
had not been under a disability from the amended alleged
onset date of October 3, 2013, through the date of the
decision. Tr. 16. Casebolt requested review of the ALJ's
decision by the Appeals Council. Tr. 9-11. On January 24,
2017, the Appeals Council denied Casebolt's request for
review, making the ALJ's decision the final decision of
the Commissioner. Tr. 1-6.
Personal, educational and vocational evidence
was born in 1963 and was 52 years old at the time of the
hearing. Tr. 25, 35, 162. Casebolt attended school until
10th grade. Tr. 35. He was in special education
classes. Tr. 35, 275-278. In 1976, the Wechsler Intelligence
Scale for Children-Revised (WISC-R) was administered to
Casebolt while he was in school. Tr. 275. The test results
showed a Verbal IQ of 81; Performance IQ of 80; and Full
Scale IQ of 79. Tr. 275.
times, Casebolt has been homeless. Tr. 295, 341. At the time
of the hearing, he was living with his girlfriend. Tr. 42.
Casebolt's past jobs included delivery driver, laborer at
a gas station, truck driver, security guard, and snow
remover. Tr. 35, 39-40.
from trying to find small jobs to make a couple of dollars
(Tr. 38) Casebolt's most recent job was at Heisler Tool
Company (“Heisler”), where he was employed from
April 20, 2015, through October 16, 2015 (Tr. 40, 44,
263-264). He was working as a delivery driver and had to load
trucks. Tr. 39-41. Casebolt was terminated from the position;
he indicated that all his employer told him was that his
“spot was being terminated.” Tr. 40-41, 265. He
noted that he did miss a lot of work because lifting and
loading pallets into the truck was strenuous activity for him
and he would get sick from straining. Tr. 40. In a
questionnaire completed by a representative of Heisler, it
was reported that Casebolt's work and attendance were
below average. Tr. 264, 267. The employer also reported that
that it was not aware of any special conditions requiring
accommodations but the following problem areas were noted -
needed instructions repeated more often than usual; problems
staying on pace; problems completing tasks; and frequent
absence. Tr. 265.
Casebolt's medical care was received a long time ago at
Mount Sinai. Tr. 295, 298. On August 19, 2014, Casebolt
sought treatment at MetroHealth with complaints of abdominal
pain. Tr. 295-304. Casebolt complained of pain starting about
two weeks earlier in his left upper quadrant. Tr. 295.
Casebolt reported a history of head trauma that occurred when
he was in his late 20s. Tr. 295. He was kicked in the head
and needed to have surgery on his left eye and face. Tr. 295.
Casebolt reported that, following that incident, he had
memory problems. Tr. 295. He also reported injuring his right
foot when he was a teenager and needing surgery. Tr. 295,
296. Casebolt relayed that he had been homeless for many
years but was living with his sister at the time of his
visit. Tr. 295, 296. Casebolt indicated he was seeking
disability for financial assistance. Tr. 295. A head MRI was
recommended in order to try to get a baseline for why
Casebolt was having memory problems. Tr. 298, 300. A CT scan
was also recommended to assess whether Casebolt had a hernia.
Tr. 300. A neuro/psych evaluation was recommended in order to
further assess Casebolt's memory loss. Tr. 298.
Casebolt's CT scan of his abdomen/pelvis showed an
umbilical hernia and bilateral inguinal hernias. Tr. 305.
October 17, 2014, Casebolt sought treatment at the
MetroHealth emergency department with complaints of abdominal
pain. Tr. 309-324. Casebolt relayed that his pain was
typically a 4-5/10 but his pain had gotten worse and was an
8-9/10. Tr. 309. Casebolt described his pain as stabbing
pressure that radiated into his back and chest. Tr. 309. He
was most comfortable in a reclining position and when putting
pressure on his abdomen. Tr. 309. His pain was worse with
standing and walking. Tr. 309. Casebolt also reported
dyspnea, a headache and visual change. Tr. 309. The attending
physician observed no concerning findings on examination. Tr.
310. Casebolt's pain resolved without intervention while
he was in the emergency room. Tr. 310. A referral was made to
general surgery because of complaints of daily symptoms but
it was noted that there was no emergent need for surgical
intervention. Tr. 310.
days later, on October 21, 2014, Casebolt saw Dr. Jonathan M.
Kwong, M.D., in the general surgery department at MetroHealth
for a consultation. Tr. 325-331. Casebolt described his
abdominal pain, noting it had gotten worse over the prior
month. Tr. 325. Casebolt indicated that his pain was
currently a 5/5 and constant. Tr. 325. He noted that the pain
was getting worse with weight lifting. Tr. 325. Dr.
Kwong's impression was epigastric and right upper
quadrant pain unrelated to his hernias. Tr. 328. Dr. Kwong
recommended a referral to GI for further evaluation of the
epigastric pain and he did not feel that surgical
intervention was necessary, unless Casebolt's hernia
symptoms worsened. Tr. 328.
October 28, 2014, Casebolt saw Dr. Stacy Beard,
Ph.D., at MetroHealth for a mental health assessment. Tr.
341-349. Casebolt reported not knowing why he was referred
for a mental health evaluation. Tr. 341. Dr. Beard noted that
Nurse Sams had made a notation regarding mood issues and
memory loss. Tr. 341. Recent stressors for Casebolt included
being homeless. Tr. 341. He was staying with family members
at the time of his assessment. Tr. 341. Casebolt reported
suicidal ideation on occasion but no history of suicidal
attempts or homicidal ideation. Tr. 341. He reported having
problems with worrying, occasionally being annoyed with
people, and anxiety. Tr. 342. Casebolt denied concentration
problems but reported poor recent and remote memory issues
due to past head injury. Tr. 342, 345. Casebolt reported
infrequent panic attacks but indicated he experienced a panic
attack about four months earlier. Tr. 342. Casebolt indicated
that, when he has a panic attack, he gets nervous and feels
like people are coming after him, his heart starts racing and
he sweats. Tr. 342. Casebolt reported some flashbacks from a
traumatic incident that occurred when he was a teenager. Tr.
342. He denied paranoia or hallucinations. Tr. 342. Dr.
Beard's diagnostic impression was “good attitude,
reported that there are things he cannot control but he tries
daily, hx of trauma. Main concern is his need to find housing
and employment, used to live w/his older sister but she moved
back to WV[.]” Tr. 346. Dr. Beard's diagnosis was
adjustment disorder, R/O PTSD. Tr. 346. Casebolt was not
interested in counseling. Tr. 346.
November 12, 2014, Casebolt saw Dr. Paul Cisarik, M.D., at
MetroHealth for abdominal pain and fatty liver. Tr. 350-364.
Casebolt complained of abdominal bloating, cramping, and
epigastric pain in the left upper quadrant - symptoms that
started about six months prior and generally occurred daily
for several hours. Tr. 350. Casebolt indicated that his pain
was worse if he went without eating. Tr. 350. He reported
early satiety over the prior month. Tr. 350. Dr.
Cisarik's assessment included fatty liver disease, GERD,
and a recommendation for a colonoscopy to screen for colon
cancer. Tr. 354. Dr. Cisarik also noted that Casebolt had a
recent diagnosis of diabetes mellitus. Tr. 354. Dr.
Cisarik's treatment notes indicate that Casebolt's
girlfriend was called to explain Casebolt's medical plan
because of Casebolt's short term memory issues and
Casebolt's request that they call his girlfriend with the
information. Tr. 354.
on November 12, 2014, Casebolt saw Dr. Ikram Khan, M.D., in
the neurology department at MetroHealth for a consultation
regarding his headaches and prior head injury. Tr. 365-373.
Dr. Khan noted that Casebolt had a normal head MRI in
September. Tr. 366. Dr. Khan's impressions/suggestions
51 year old male seen in consultation for headaches likely
migraines with aura. His MRI [is] negative for acute
pathology. He is undergoing workup for his liver and
epigastric pain that limits prescribing him pain medication.
[N]o visual symptoms[.]
Khan prescribed Neurontin and advised him to return in six
weeks. Tr. 369-370.
had a colonoscopy on November 26, 2014. Tr. 374-414, 419-422.
The post-procedure diagnoses were esophageal reflux; duodenal
ulcer, unspecified as acute or chronic, without hemorrhage,
perforation or obstruction; and colonic polyp. Tr. 687.
December 2, 2014, Casebolt saw Nurse Sams. Tr. 423-440.
Casebolt reported that his GERD was better but he was
continuing to have headaches. Tr. 423. He relayed that he had
applied for SSI but he was still trying to find work. Tr.
423. He was still sleeping in his van but hoping to move in
with his girlfriend that week. Tr. 423. At Casebolt's
request, Nurse Sams spoke with Casebolt's girlfriend over
the phone because of his short term memory issues. Tr. 424.
Nurse Sams provided a care plan for Casebolt, which included
medication to treat his diabetes mellitus and GERD. Tr.
December 17, 2014, Casebolt saw Dr. Khan. Tr. 441-449. Dr.
Khan noted that Casebolt was continuing to have headaches but
Neurontin had helped so Dr. Khan increased Casebolt's
dosage of Neurontin. Tr. 442, 445. That same day, Casebolt
saw Dr. Cisarik for a follow-up visit. Tr. 450-461. Casebolt
reported having much less abdominal pain. Tr. 450. He relayed
that, if he forgets to take his medication, he gets left
upper quadrant epigastric pain but had not had pain for at
least three weeks. Tr. 450. Other than a random episode of
heartburn when eating pizza, he had not had heartburn. Tr.
450. He was uncertain as to all the medications he was taking
but noted that he had his medications in his van. Tr. 450.
Dr. Cisarik counseled Casebolt regarding his various tests,
procedures, and medication. Tr. 456.
January 19, 2015, Casebolt saw Dr. Neil F. Sika, OD, at
MetroHealth for a diabetes mellitus eye examination. Tr.
462-479. Casebolt reported occasional blurring and pain in
his left eye. Tr. 462. He only wore over-the-counter reading
glasses. Tr. 462, 463. For about a year, Casebolt had been
experiencing occasional white flashes. Tr. 462. Dr. Sika
diagnosed a compound hyperopic astigmatism in the right eye,
hyperopia in the left eye, and presbyopia in both eyes. Tr.
464. Dr. Sika provided Casebolt with a prescription for
eyeglasses. Tr. 464. However, Casebolt did not have insurance
to cover the cost so Dr. Sika recommended that Casebolt use
over-the-counter reading glasses and monitor the situation
over the next year. Tr. 464. Dr. Sika found no
nonproliferative diabetic retinopathy at the time but advised
Casebolt to keep tight control on his diabetes mellitus. Tr.
October 9, 2015, Casebolt saw Dr. Gwen Haas, M.D., at Lake
Health, to establish a primary care physician relationship.
Tr. 484-486. Casebolt complained of headaches and memory
issues since being kicked in the head and he also complained
of low back pain, foot numbness and a hernia. Tr. 484.
Casebolt also relayed that he had a history of GERD and
diabetes mellitus. Tr. 484. On examination of Casebolt's
abdomen, Dr. Haas observed a ventral herniation without
strangulation. Tr. 484. Dr. Haas's musculoskeletal
examination was negative for erythema, swelling or joint
deformities but Dr. Haas noted that Casebolt was positive for
lumbar vertebral tenderness to percussion with no rashes. Tr.
484. Dr. Haas's examination of Casebolt's extremities
was generally normal with slightly diminished patellar
reflexes on the left. Tr. 484-485. Dr. Haas ordered blood
work, provided prescriptions for treatment of sciatica, GERD,
and diabetes mellitus. Tr. 485. Casebolt declined a surgical
consultation for his ventral hernia. Tr. 485.
February 14, 2014, Casebolt saw Dorothy A. Bradford, M.D.,
for a consultative physical evaluation. Tr. 279-287. Casebolt
relayed numerous complaints - headaches, low back pain, knot
in stomach that hurt when trying to lift or sit up, right
foot pain, and left knee pain. Tr. 284. Casebolt reported
that he did not use an assistive device and he could
walk/stand for 20 minutes and lift 50 pounds. Tr. 284. Dr.
Bradford's physical examination was generally normal. Tr.
285-286. For example, Casebolt exhibited normal range of
motion, stability, strength and tone in all extremities and
in the head and neck. Tr. 286. Casebolt's gait was
normal. Tr. 286. Dr. Bradford observed Casebolt's
judgment and insight to be appropriate; he was oriented to
person, place and time; he had normal recent and remote
memory; his mood and affect were appropriate; his language
was normal; and his speech had a normal rate, articulation,
and spontaneity. Tr. 287. Dr. Bradford opined that:
Claimant has had multiple musculoskeletal injuries as
outline[d] above and now has pain that is probably due to
DJD. On exam he has a very large and tender diastasis
recti. In my medical opinion he should be
restricted to sedentary activity.
9, 2014, state agency reviewing physician Eli Perencevich,
D.O., completed a physical RFC assessment. Tr. 87-89. Dr.
Perencevich opined that Casebolt had the RFC to lift/carry 20
pounds occasionally and 10 pounds frequently; stand/walk
about 6 hours in an 8hour workday; sit about 6 hours in an
8-hour workday; and push and pull unlimitedly, other than as
indicated for lift/carry. Tr. 87. Dr. Perencevich's
exertional limitations were based on reported pain and
diastasis recti. Tr. 87. Dr. Perencevich opined that Casebolt
had the following postural limitations - frequently climb
ramps/stairs, never climb ladders/ropes/scaffolds,
occasionally stoop, kneel and crouch, and never crawl. Tr.
87-88. Dr. Perencevich's postural limitations were due to
Casebolt's 12 inch diastasis recti. Tr. 88. Dr.
Perencevich also opined that Casebolt would have to avoid
concentrated exposure to vibration and even moderate exposure
to hazards (machinery, heights, etc.). Tr. 88.
March 14, 2014, Casebolt saw Dr. J. Joseph Konieczny, Ph.D.,
for a consultative psychological evaluation. Tr. 288-294. Dr.
Konieczny observed that Casebolt was pleasant and cooperative
and occasionally vague in his presentation but responsive to
all questions and tasks posed to him. Tr. 289, 290. When
asked about his current disability, Casebolt stated, “I
have a lack of memory since I had my head kicked in.”
asked about his education, Casebolt relayed that he was
involved in special education classes and repeated eighth
grade. Tr. 290. He stated he dropped out of school during his
tenth grade year because his parents moved. Tr. 290. He
indicated he had participated in some adult education but did
not obtain his Graduate Equivalency Diploma. Tr. 290.
was unable to recall when he was assaulted but he relayed he
was knocked unconscious, has had ongoing headaches and left
visual deficits, and significant memory problems. Tr. 290.
Konieczny observed that Casebolt's ability to concentrate
and attend to tasks showed no indications of impairment. Tr.
291. Casebolt performed serial three subtraction without
error but his responses were slow. Tr. 291. He showed
moderate deficits in his ability to perform logical abstract
reasoning. Tr. 291. Dr. Konieczny observed that Casebolt
exhibited mild deficits in his overall level of judgment and
opined that Casebolt “would appear to require some
degree of supervision and monitoring in the management of his
daily activities and in handling his financial
affairs.” Tr. 291. Casebolt's WAIS-IV Full Scale IQ
score was 74, which Dr. Konieczny opined placed him in the
borderline range of adult intellectual functioning ...