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Casebolt v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

February 21, 2018




         Plaintiff 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 Commissioner's decision.

         I. Procedural History

         On December 24, 2013, Casebolt protectively filed[1] an application for Supplemental Security Income (“SSI”).[2] 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. 32-47.

         In his 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.

         II. Evidence

         A. Personal, educational and vocational evidence

         Casebolt 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.[3] Tr. 275.

         At 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.

         Aside 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.

         B. Medical evidence

         1. Treatment history

         Most of 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.

         On 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.

         A few days later, on October 21, 2014, Casebolt saw Dr. Jonathan M. Kwong, M.D., in the general surgery department at MetroHealth for a consultation.[4] 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.

         On October 28, 2014, Casebolt saw Dr. Stacy Beard, [5] 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.

         On 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.

         Also, 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 were:

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[.]

Tr. 369.

         Dr. Khan prescribed Neurontin and advised him to return in six weeks. Tr. 369-370.

         Casebolt 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.

         On 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. 424-425.

         On 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.

         On 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. 464.

         On 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.

         2.Medical opinion evidence

         Physical impairment opinions

         On 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.[6] In my medical opinion he should be restricted to sedentary activity.

Tr. 287.

         On July 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.

         Mental impairment opinions

         On 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.” Tr. 289.

         When 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.

         Casebolt 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.

         Dr. 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 ...

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